10/03/2017 - 1:07am Interested in an engaging speaker or trainer for your next event? Complete this form to submit your request. First Name * Last Name * Email Address * Phone Number * Is there any MIUSA staff you have already been in contact with regarding this event? Event Name * Organization hosting the event * Event Street Address * Event Location * Event Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2021202220232024 Brief description of the event * Event Estimated Attendance * Brief description of the audience * We are able to cover travel expenses of the speaker (and, when necessary, of a support person) * - Select -YesNo Leave this field blank