MLGW SPEAKER/EVENT PARTICIPATION REQUEST FORM

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1. Event Name

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2. Event Type

Community Resource Expo

Health Fair

Community Meeting

Professional Meeting

School Event

Other (please specify)

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3. Event Date

Date

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4. Event Begin Time

Time

AM/PM

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5. Event End Time

Time

AM/PM

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6. If this is a speaker request, how much time is allotted for the speaker?

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7. Contact Person Information

Contact Name

Host Organization

Contact Email Address

Contact Phone Number

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8. Event Location Information

Name of Event Location

Room Number and/or Name

Event Location Address

City/Town

State/Province

ZIP/Postal Code

Event Location Phone Number

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9. Is this event open to the public?

Yes

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10. Please indicate which items are to be provided by the event host.

Table

Chairs

Tent

Electricity

Projector/Television/Screen

Other (please specify)

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11. Information/Speaker Request Topic

Careers

Career-on-Wheels (Limited to School Groups)

Terminator/Electrical Safety (Limited to School Groups)

Energy Conservation

Memphis Aquifer/Water Conservation

Kids Conservation Workshop

Conservation Girl Appearance

Financial Literacy

Special Assistance Programs

Water Quality

Utility Safety

Outages/Outage Restoration

EnergySmart Workshop

Rental Energy Efficiency Ordinance

My Account

MLGW Credit Policies

Senior Programs

Senior Bingo

Water Pumping Station Tour (Limited to Schools)

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12. Estimated Number of Event Attendees

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13. If attendees are children, please indicate the age range.

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14. Other Event Details that you would like to share.

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15. How did you find out about the MLGW Speakers Progam?

MLGW Call Center

MLGW Community Outreach Newsletter

MLGW Customer Connection (MLGW Bill Insert)

MLGW Website

MLGW Employee

Saw MLGW Participating in Community Event

Other (please specify)

MLGW SPEAKER/EVENT PARTICIPATION REQUEST FORM

Question Title

* 1. Event Name

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* 2. Event Type

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* 3. Event Date

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* 4. Event Begin Time

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* 5. Event End Time

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* 6. If this is a speaker request, how much time is allotted for the speaker?

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* 7. Contact Person Information

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* 8. Event Location Information

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* 9. Is this event open to the public?

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* 10. Please indicate which items are to be provided by the event host.

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* 11. Information/Speaker Request Topic

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* 12. Estimated Number of Event Attendees

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* 13. If attendees are children, please indicate the age range.

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* 14. Other Event Details that you would like to share.

Question Title

* 15. How did you find out about the MLGW Speakers Progam?

1. Event Name

2. Event Type

3. Event Date

4. Event Begin Time

5. Event End Time

6. If this is a speaker request, how much time is allotted for the speaker?

7. Contact Person Information

8. Event Location Information

9. Is this event open to the public?

10. Please indicate which items are to be provided by the event host.

11. Information/Speaker Request Topic

12. Estimated Number of Event Attendees

13. If attendees are children, please indicate the age range.

14. Other Event Details that you would like to share.

15. How did you find out about the MLGW Speakers Progam?