Document g01L39ZK3zY6z3kOJeZ131Oq

ADMINISTRATOR SCOTT PRUITT SPEAKER REQUEST FORM U.S. Environmental Protection Agency Deadline for Acceptance: Event Title: Speech Date: Is the Above Date Flexible: Speech Time & Duration: Requesting Group: Would You Consider a Surrogate: Event Location: Is there a Hold Room Available for the Administrator?: Open Press/Closed Press?: Is Event Webcast/Recorded/Transcribed: Purpose of the Event: Requested Speech Topic: Requested Presentation Format: Dress Code: Speech/Presentation Duration: Teleprompter Available: Microphone/ Room Setup: Location Name Street Address, City, State, Zip Location Telephone Number Room Name/Number If yes, please specify Brief Description Keynote, Panel, Q&A, Introduction, etc. Casual/Business/Black Tie Optional/Black Tie/Etc. Length of Remarks What kind of microphone will be used? What is the room setup? 17cv01906 Sierra Club v. EPA Page 1 of 3 ED_001523B_00002194-00001 Event Sponsors: i'ii'? " -2',;;; Lisf"'an.Spnnsors (businesses, schools or universities, etc.) ADMINISTRATOR SCOTT PRUITT SPEAKER REQUEST FORM U.S. Environmental Protection Agency Relationship to the EPA: Run of Show/ Agenda: Provide full agenda of the event, including events immediately following the Administrator speaking. Honorable Guests Attending: Name & Title Notable Federal, State or Local Appointed or Elected officials attending: Name & Title Individual Introducing Administrator: Name & Title Event Audience: Brief description and size of audience 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 organization or host of the event a registered 501(c)(3), (4), or has a 527 Political Action Committee (PAC): 17cv01906 Sierra Club v. EPA Page 2of 3 ED_001523B_00002194-00002 ADMINISTRATOR SCOTT PRUITT SPEAKER REQUEST FORM U.S. Environmental Protection Agency Will there be a presentation of a "gift" 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? 17cv01906 Sierra Club v. EPA Page3 of 3 ED_001523B_00002194-00003