Speaker Request Form

This form is provided to request a State's Attorney Speaker.

Please take a moment to answer the following questions.

(NOTE: Your name and address will not be transferred to any other organization unless
required by law.)

Speaker: What is the topic for which you are requesting a speaker?

Choose from the following list:
Environmental Crime, Domestic Violence, Victim/Witness Assistance, Sexual Assault,
Drugs, Gangs, Hate Crimes, Crimes Against the Elderly, and Consumer Fraud.
Also available for grades 1st through 4th is the
State's Attorney's Anti-gang/Anti-drug "Puppet Patrol".
* Note: Bilingual speakers are available on request. *

Date of Presentation:

Organization or Group:

Contact Person:

Phone Number:

Email Address: What is your e-mail address?
If you wish to receive an electronic acknowledgement of your request,
you must provide a valid e-mail address.

Please provide your physical mailing address.
A valid street address must be provided.

        Street Address     
        City               
        State/Province     
        Zip                
        Country

Location presentation is to be given.

        Street Address     
        City

This area is provided for those who wish to send a message, in addition to requesting a speaker.

the Message Now and Start Over