Document EdNjDp453vjrG3QjKxrqRexbL

ADMINISTRATOR SCOTT PRUITT EVENT REQUEST FORM U.S. Environmental Protection Agency Deadline for Acceptance: Requesting Individual / Affiliation: Event Title: Event Date: Is the Above Date Flexible: Event Time & Duration: Type of Event: Purpose of the Event: Role of the Administrator: Requested Presentation Topic, if Speaking Involved: Requested Presentation Format: Speech/Presentation Duration: Would You Consider a Surrogate: Event Location: Event Audience: Event Host(s)/Organizer(s): Host(s)' Relationship to EPA: Reception, Conference, Meeting Brief Description E.g., speaking engagement, keynote, panel, roundtable, attendance Keynote, Panel, Q&A, Introduction, etc. Length o f Remarks Location Name Street Address, City, State, Zip Location Telephone Number Room Name/Number Size o f audience and brief description. E.g., 100 in attendance made up o f attorneys, business owners, students, industry, employees, etc. List all hosts organizing the event 17cv01906 Sierra Club v. EPA Page 1 of 2 ED 001523B 00006169-00001 Run of Show/ Agenda: Provitf&rull agenda o f the event, including events ADMINISTRATOR SCOiT P ^ W i ^ f m '? ' is there a Hold Room AvrWaSe Erwironmental Protection Agency Administrator? Open Press/Closed Press? Dress Code: Casual/Business/Black Tie Optional/Black Tie/Etc. Teleprompter Available: Microphone / Room Setup: What kind o f microphone will be used? What is the room setup?_________________________________________ Honorable Guests Attending: Name & Title Notable Federal, State or Local Name & Title Appointed or Elected officials attending: ____________ Individual Introducing Administrator: Name & Title Person to contact for media purposes: Name & Title; Email; Office Number, Cell Number Is this event held Weekly, Monthly, Annually? Day of Event Point of Contact: Name & Title; Email; Office Number, Cell Number Security Contact: Name & Title; Email; Office Number, Cell Number Suggested Entrance/ Exit to Event Venue: Is the host of the event a registered 501(c)(3), (4), or has a 527 Political Action Committee (PAC): Will there be a "gift" presented to the Administrator? If so, what is the US currency value of the gift? Will a meal be provided, if so what is the US currency value? Please return this form completed to schedulingfcp.epa.gov and Sydney Hupp (hupp.svdnevfib.epa.aov). 17cv01906 Sierra Club v. EPA Page 2 of 2 ED 001523B 00006169-00002