Document x11R1j6x5DX7j2o7J9VdGRw1b

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: _________________________________________________ _________________________________________________ Reception, Conference, Meeting B r i e f Description_________________________________ E.g., speaking engagement, keynote, panel, roundtable, attendance_______________________________________ Keynote, Panel, Q&A, Introduction, etc. Length o fRemarks Would You Consider a Surrogate: Have you requested or are you planning to request anyone else from EPA to speak or attend this event? Name & Titie 0f ppA personnel Event Location: Event Audience: Event Host(s)/Organizer(s): Host(s)' Relationship to EPA: Run of Show/ Agenda: Size o f audience and briefdescription. E.g., 100 in attendance made up o fattorneys, business owners, students, industry, employees, etc._________________________________________ List all hosts organizing the event_________________________ ________________________________________________________ Provide f i l l agenda o f the event, including events immediately following the Administrator speaking.______________________ Page [P A G E ] of l NUMPAGES j Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00065748-00001 ADMINISTRATOR SCOTT PRUITT EVENT REQUEST FORM U.S. Environmental Protection Agency Is there a Hold Room Available for the 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 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 How will you promote this event? 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. hayleyCdiepa. gov Sierra Club v. EPA 18cv3472 NDCA Tier 1 Page [P A G E ] of l NUMPAGES j ED 002061 00065748-00002