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Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Date of Event

YYYY

Location of Event

Please include the Location, Street Address, City, and State

Event Description

What is the nature and setting of the event? Who will be attending? For what purpose?

Request Description

What are you requesting Ben McBride to do? Is there a theme for the talk? For how long? Are there multiple sessions?

Additional Information

Is there anything additional you would like to share that will help us understand the purpose and function of your event?