Document evvrdvyZz9OxLva61DB0RLyBG

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: Reception, Conference, Meeting Purpose of the Event: B rie fDescription_________________________________ Role of the Administrator: E.g., speaking engagement, keynote, panel, roundtable, attendance Requested Presentation Topic, if Speaking Involved: Requested Presentation Format: Keynote, Panel, Q&A, Introduction, etc. Speech/Presentation Duration: Length o fRemarks Would You Consider a Surrogate: Event Location: Location Name Street Address, City, State, Zip Location Telephone Number Room Name/Number Event Audience: Size o f audience and briefdescription. E.g., 100 in attendance made up o f attorneys, business owners, students, industry, employees, etc. Event Host(s)/Organizer(s): List all hosts organizing the event_________________________ Host(s)' Relationship to EPA: Run of Show/ Agenda: Provide fu ll agenda o f the event, including events immediately follow ing the Administrator speaking. Is there a Hold Room Available for the Administrator? Page [P A G E ] of l NUMPAGES j Sierra Club v. EPA 18cv3472 NDCA Tier 5 ED 002061 00058783-00001 ADMINISTRATOR SCOTT PRUITT EVENT REQUEST FORM U.S. Environmental Protection Agency 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 Appointed or Name & Title 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 completedform to Hayley Ford at ford. havlev(a),epa. gov Sierra Club v. EPA 18cv3472 NDCA Tier 5 Page [P A G E ] of l NUMPAGES j ED 002061 00058783-00002