Fill out the form below and we will be in touch. Name of organization*Date of eventMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920When you will need us to be thereContact Person* First Last Email* name@domain.comPhone*(555)555-5555Title of event*Please describe purpose or objectives of your eventEstimated number of attendees*Description of audience members*Please describe degrees, occupations or level of experience.Location of event* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Budgeted honorarium/expenses*Will there be audio visual equipment available?*YesNoIf yes, please describe auto/visual availability and restrictionsAre you interested in having PPD books available for sale?*YesNoAre you interested in a book signing?*YesNoDo you have a preference for Karen Kleiman to present?*YesNoAny additional requests?Please note there is no authorization for recording of any kind during this event unless prior consent has been given. Check YES to agree with these terms.YesNoEmailThis field is for validation purposes and should be left unchanged.
