Document zQDEDkGjL6wzKajnnMnKKRkZz

ADMINISTRATOR PRUITT SPEAKER REQUEST FORM U.S. Environmental Protection Agency Deadline for Acceptance: [Publication or otherwise; please see details below] Event Title: [Enter Here] Speech Date: Is the Above Date Flexible: [Day of the Week, Month Date, Year] [Yes/No] Speech Time & Duration: [#:##am/pm - ##:##am/pm] Speaker Requested: Administrator Scott Pruitt Would You Consider a Surrogate: Event Location: [Yes/No] [Location Name] [Street Address, City, State, Zip] [Location Telephone Number] [Room Name/Number] Open Press/Closed Press: [Open/Closed/TBD] Is Event Webcast/Recorded/Transcribed: Purpose of the Event: [Yes/No] [If Yes, please specify] [Enter Brief Description] Speech Topic: [Topic] Requested Presentation Format: [Keynote, Panel, Q&A, Introduction] Dress Code: Speech/Presentation Duration: [Casual/Business/Black Tie Optional/Black Tie/Other] [Length of Remarks] Teleprompter Available: [Yes or No] Microphone/ Room Setup: [What kind of microphone will be used? What is the room setup?] Event Sponsor: [List all Sponsors] Relationship to the EPA: Event Agenda/Program: [Enter Here] [Time: Program/Agenda Item] [Time: Program/Agenda Item] [Time: Program/Agenda Item] [Time: Program/Agenda Item] Honorable Guests Attending: [Name/Title] Notable Federal, State or Local Appointed or Elected officials attending: Individual Introducing Administrator: [Name/Title] [Name/Title] Page 1 of 2 17cv01906 Sierra Club v. EPA ED_001523B_00003442-00001 ADMINISTRATOR PRUITT SPEAKER REQUEST FORM U.S. Environmental Protection Agency Person to contact for speechwriting purposes: [Name/Title] [Email] [Office Number] [Cell Number] Person to contact for media purposes: [Name/Title] [Email] [Office Number] [Cell Number] Origin of Invitation: [Name/Title] [Email] [Office Number] [Cell Number] Day of Event Point of Contact: [Name/Title] [Email] [Office Number] [Cell Number] Security Contact: [Name/Title] [Email] [Office Number] [Cell Number] Is the organization or host of the event a registered 501(c)(3), (4), or has a 527 Political Action Committee (PAC): 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 Page 2of 2 ED_001523B_00003442-00002