Document b5jyYG1J8q3rZL74Zjwkj5Np6

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, etc BriefDescription E.g., speaking engagement, keynote, panel, roundtable, attendance Keynote, Panel, Q&A, Introduction, etc. Length ofRemarks Location Name Street Address, City, State, Zip Location Telephone Number Room Name/Number Size ofaudience and briefdescription. E.g., 100 in attendance made up ofattorneys, business owners, students, industry, employees, etc. List all hosts organizing the event 17cv01906 Sierra Club v. EPA Page 1 of 2 ED_001523B_00000075-00001 Run of Show/ Agenda: i '{;, s ffi ~ ~ \ + i<'+J- e,<..'o Provfcff!"jull agenda ofthe event, including events immediately ADMINISTRATOR scoffffitfttt''lt'W~f ~EST FORlV[ Is there a Hold Room Availab1ll~t1invironmental Protection Agency Administrator? Open Press/Closed Press? Dress Code: Casual/Business/Black Tie Optional/Black Tie/Etc. Teleprompter Available: Microphone/ Room Setup: What kind ofmicrophone will be used? What is the room setup? Honorable Guests Attending: -N- am-e &- - Tit- le - - - - - - - - - - - - - - - - - - - - Notable Federal, State or Local Appointed or Name & Title Elected officials attending: Individual Introducing Administrator: Person to contact for media purposes: -N- am-e &- - Tit- le - - - - - - - - - - - - - - - - - - - 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 scheduhng(ii1epa.gov and Aaron Dickerson at dickerson.aaron(a'1ez a.gov 17cv01906 Sierra Club v. EPA Page 2of 2 E D _001523B _ 0000007 5-00002