Form n//a CISA Speaker Request Form

OMB Control No: 1670-NEW
OMB Expiration Date: MM/DD/YYYY

SPEAKER REQUEST FORM
Please submit this form and corresponding attachments to [email protected]
* Please submit speaking requests at least 4 weeks in advance of the event.
Event Title (Official title of event):
Event Date:

Speaker Requested (Name and title of speaker requested):

Event Time and Duration (List time of event):

Origin of Invitation (Name of organization submitting request):

Event Location:
Mailing Address:

Name:

City:

Phone:

State:

Choose State

Speech Topic (Define topics/points you wish the speaker to cover):

Presentation Format:

Keynote speech

Roundtable

Panel

Chat

Webinar

Other

Event Type:

Small Group

Dinner

Questions & Answer Period:

Yes (specify duration):

Conference

"Fireside"

Other

No

Audience (Anticipated number of attendees; audience background; whether membership is required):

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Open Press/Closed Press:
Yes (If media is invited, please provide a list. If applicable, please provide a point of contact for media
relations):
No, closed to Press

May CISA invite media?

Yes

No

Speaker Relationship (Does the speaker have any existing personal or professional relationship with the
event sponsor, hosting organization, or group before whom he/she is speaking? For example, does the
speaker or a close family member have a personal membership in or employment /volunteer relationship with
the organization? If so, please explain):

Surrogate Requested (If principal is unavailable, will you accept a surrogate? If so, do you have a preference?):

Purpose (Describe in two sentences or less):

Cost of Attendance (Please include member and non-member price if applicable):

Event Web Site:

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Will the event be live streamed, either on this site or elsewhere?
No

Yes, Livestream site:

Event sponsor (List event sponsors and co-sponsors):

For Profit

Not for Profit

Offer of Payment/Reimbursement (Dining, lodging, travel):

Event Agenda (Please place text version of event agenda below, please highlight speaker requested):

Disclaimer/Release Form (Please indicate whether
or not the event sponsor has asked the speaker to
sign a disclaimer/release form:

Deadline for Acceptance: (For planning,
publicizing, etc. Please submit 4 weeks in
advance of the event):

Choose an option
Attach Form

Honorable Guests Attending (List name/titles of members of Congress, CEOs, or VIPs participating or
attending the event:

Coordinator Point of Contact (Name, title, email, office phone, cell phone):

Submit by Email
Privacy Act Statement: Authority: 5 U.S. C. § 301 and 44 U.S.C. § 3101 authorize the collection of this information. Purpose: CISA will use this information to
coordinate, support, and track external speaking engagements for the Cyber/Infrastructure-related speaking requests. CISA will also use the submitted information
to identify the most appropriate CISA speaker for specific speaking engagements if necessary. Routine Use: This information may be disclosed as generally permitted
under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using the information, as necessary and authorized by the routine uses published in
DHS/ALL-002 - Department of Homeland Security (DHS) Mailing and Other Lists System of Records (November 25, 2008, 73 FR 71659). Disclosure: Failure to
provide the requested speaker's information will result in their inability to participate in this speaking engagement.
Paperwork Reduction Act Burden Statement: This public reporting burden to complete this information collection is estimated at 15 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and reviewing the collected
information. The collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number and expiration date. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to DHS/CISA/External Affairs, 245 Murray Lane, SW, Mail Stop 0380, Washington DC 20598-0609,
ATTN: PRA [OMB Control No. 1670-NEW].

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