Document EmDpV9xDd5wyzq7L9a9xd1Rpn

ADMINISTRATOR SCOTT PRUITT EVENT REQUEST FORM U .S. Environmental Protection A gency Deadline for Acceptance: Requesting Individual / Affiliation: Event Title: Event Date: Is the Above Date Flexible: Event Tim e & Duration: Type of Event: Purpose o f the Event: Role o f the Administrator: Requested Presentation Topic, if Speaking Involved: Requested Presentation Format: Speech/ Presentation Duration: Would You Consider a Surrogate: Event Location: Event Audience: E ven t Host(s)/ O rganizers): Host(s)' Relationship to EPA: Run of Show/ Agenda: Is there a Hold Room Available for the Adm inistrator? Reception, Conference, Meeting__________________ B rief 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___________________________ Provide fu ll agenda o f the event, including events immediately following the Administrator speaking._______ Page [ P A G E ] of [ NUMPAGES j Sierra Club v. EPA 18cv3472 NDCA Tier 7 ED 002061 00067520-00001 ADMINISTRATOR SCOTT PRUITT EVENT REQUEST FORM U .S. Environmental Protection A gency 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: Notable Federal, State or Local Appointed or Elected officials attending: Individual Introducing A dm inistrator: Name 8s Title Name 8s Title Name 8s Title Person to contact for media purposes: Name 8s Title; Email; Office Number, Cell Number ___________________________________________________________________________ Is this event held W eekly, M onthly, A n n u a lly ? Day o f Event Point o f Contact: Name 8s Title; Email; Office Number, Cell Number Security Contact: Name 8s Title; Email; Office Number, Cell Number Suggested Entrance/ Exit to Event Venue: Is the host o f the event a registered 501(c)(3), (4), or has a 527 P olitical A ction Com m ittee (PAC): Will there be a "g ift" presented to the Adm inistrator? If so, what is the U S currency value o f the gift? Will a m eal be provided, if so what is the US currency value? Please return this form completed to schedulingCcepa.gov and Sydney Hupp (hupp. sijdneg epa. gov). l Page [P A G E ] o f NUMPAGES j Sierra Club v. EPA 18cv3472 NDCA Tier 7 ED 002061 00067520-00002