2. Event Name*
4. Event Description*
6. Event Address*
8. City*
9. State*
10. Zip Code*
12. Start Date and Time*
    Start Date and Time

    Start Date and Time
13. End Date and Time*
    End Date and Time

    End Date and Time
15. Attach Invitation or Flyer (if applicable)
17. Attendance*

    1. Less than 50
    2. 50 - 100
    3. 100 - 250
    4. Over 250
    5. Other
18. Type of Remarks*

    1. Keynote Speech
    2. Welcome / General Remarks
    3. Panel or Q and A Session
    4. None
    5. Other
19. Duration of Remarks*

    1. Less Than 5 Minutes
    2. 5 - 10 Minutes
    3. 10 - 15 Minutes
    4. Not Applicable
    5. Other
21. If "Other" please explain:
23. Notable Attendees
24. Additional Information
26. Press Information*

    1. Event is open to press and organizers will do outreach
    2. Event is open to press, but no outreach
    3. Event is closed to press
27. Is this an Annual Event?*

    1. Yes
    2. No
    3. First Time, but plan to be annual
29. Contact - First Name*
30. Contact - Last Name*
32. Contact Title*
33. Organization*
35. Email*
36. Phone*
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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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