Contact Phone Number:
Contact E-Mail Address:
Organization Name:
(If available, include website, any political affiliation and Mission Statement)
Organization Website:
Organization Political Affiliation:
Mission Statement:
Date and Time of Event: (Include anticipated Speaker time)
Location of Event:
Anticipated Audience Size:
Will there be other Speakers?
Will there be Media Coverage?
Purpose of Event:
Topics/Discussion:
Certifications: I have read the terms and conditions of the Judicial Ambassador Program and accept all the terms and conditions of the Program.
Disclaimer
Not all requests will be honored.