SPEAKER REQUEST FORM
Fill out this form: email or mail to William Dickerson-Waheed 505 John Hart Street, Jackson,Ms.39202
wwaheed16@hotmail.com 601.594.6792
Contact Person:
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Organization:
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Mailing Address:
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City:_____________________________________________State:____________Zip:_______________
Phone:Office_______________________________________Cell:_______________________________
Email:_____________________________________________________Fax:______________________
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EVENT
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Conference Theme:
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Location/Venue__________________________________________________Date of Event__________
Address of Venue:
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City:_______________________________________________State:______________Zip:___________
Number of People expected in attendance:___________________________
Will there be an opportunity for vending:________________
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Presentation Requested:
___Keynote Speech___Conference Workshop__Professional Development__Presentation to Students__Community Presentation
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