LPI / DSLS Speakers Bureau

Houston Region Speaker Request
Request for a Specific LPI / DSLS Speaker

*Indicates a required field.

*First Name:     *Last Name:  

Affiliation:  

*Telephone #:  

*E-mail:  

*Name of Event/Meeting  

*Date:      *Start Time:  

*Length of Program:  

Location of Event:
*Name of Building:  

*Street Address:  

Room Number:  

*City:     *State:  *Zip:  

Contact Person for the Event (if different than above):   

Contact's Telephone Number:  

Contact's E-Mail Address:  

Audience (audience #, age, other information that will help us identify the most appropriate speaker)

*Topic:  

If topic is "Other", please describe:

Speaker: (If you wish to have a particular LPI/DSLS speaker)  

Is this talk a part of a broader education program? (e.g., ongoing classroom investigation, series of speakers, outreach day, etc.)

Questions/Additional Information