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Exploring Chemical Sciences Classroom Speakers request form
Exploring Chemical Sciences Classroom Speakers request form
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Your Name
First
Last
Your email address
A phone number where you can be reached during the day
Name of the requesting group or organization
Please provide a descriptive title for your event
Date you wish to schedule speaker's visit
Please indicate an alternate date for speaker's visit
Please indicate another alternate date for speaker's visit
Desired start time for the speaker's talk
Is your start time flexible?
Yes
No
What is the street address of the location where this event will be held?
Who wil the audience be?
If you indicated "Other" in the question above, please describe your audience.
Anticipated audience size
Topics you would like the speakers to cover.
Special requests or any questions you might have:
Submit
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