TSA Speaker Requestor

OMB 1652-xxxx
Exp. xx/xx/xxxx

(Agency Name) Speaker Request Form

Thank you for your interest in having a (agency name) speaker at your event. In order to help us facilitate your
request, please complete and submit the following form (and any corresponding attachments) to (agency email
address) at least 2 weeks prior to the event, and allow 3-5 business days for decisions to be made.

Name of Organization Submitting
Request

Event Sponsor(s)
For Profit/Nonprofit
Coordinator/Point of Contact
(Name, title, email, office phone,
cell phone)

Event Name/Title

Event location (Address, or virtual
information)

Event Date/Time & Time Zone
Event Type (Conference, dinner,
small group, etc.)

1

Event purpose/Goal

Event website
Agency Requested topics

Insider Risk
Surface
Checkpoint Strategy
Utilizing Authorities to Better Execute Mission
Improved Outcome-Focused Policy Development, Compliance
and Oversight
Workforce Support
Cybersecurity
Crisis Management
COVID-19
Hurricanes
Wildfires
REAL ID
Precheck
TSA 101
Civil Rights and Liberties
Unmanned Aircraft Systems
Federal Air Marshals
Other

2

Presentation format (Keynote
address, roundtable, panel, etc.)
Expected duration
Question and Answer (Will the
speech be followed by a Q&A
session?)
Audience (Approximate number of
attendees, also describe the makeup and if membership is required.)

Honorable guests (List names and
titles of members of Congress,
CEOs, or other VIPs participating
in, or attending the event.)

Media (Will media be invited to
the event? If so, describe and
submit a media list.)

Other Notes, (Please
include the cost of
attendance for audience
members, if any; specify
whether a release form is
required; if travel
reimbursement offered,
please specify; and feel
free to include any other
relevant information you
would like to provide.)

Paperwork Reduction Act Burden: TSA will use the information to collect information on the requestor and the event a speaker would attend.
This is a voluntary collection. It is estimated that the total annual burden per response associated to this collection is approximately 10 minutes. An
agency may not conduct or sponsor, and a person is not required to respond to a collection of information, unless it displays a valid OMB control
number. The control number assigned to this collection is OMB-1652-xxxx, which expires x/xx/xxxx. Send comments regarding this burden
estimate or any other aspect of this collection of information including suggestions for reducing this burden to TSA PRA Officer, 6595 Springfield
Drive, Springfield, VA 20598-6011. ATTN: PRA 1652-xxxx.