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2. First Name*
3. Last Name*
5. Group/Organization Name*
7. Phone*
8. Email*
10. Street Number*
11. Street Name*
12. Street Type*
13. Apt #
15. City*
16. State*
17. Zip*
19. Topic Requested*
    -- Select One --Department of HealthCounty AdministrationPreparing for an EmergencyGrantsHuman ResourcesLivingston County HistoryPlanning/Renewable EnergyPublic Defender's OfficePublic InformationRecords ManagementResources for Older Adults in Livingston CountySuicide Prevention and AwarenessWorkforce Development
21. Requested Presentation Date*
    Requested Presentation Date
22. Requested Presentation Time*
    Requested Presentation Time

24. Livingston County will make every effort to accommodate your request, however, we cannot guarantee a speaker's availability

25. Livingston County will make every effort to accommodate your request, however, we cannot guarantee a speaker's availability

27. Anticipated Speaking Duration*
    -- Select One --5 Minutes of Fewer10 Minutes15 Minutes30 Minutes45 Minutes60 Minutes or More
28. Anticipated Audience Size*
    -- Select One --1-10 People11-20 People21-30 People31-40 People41-50 People51 People or More
30. Goals of the Presentation*

32. Please include your learning objectives and goals to better shape the presentation

34. In-Person or Virtual Presentation*

    1. In-Person
    2. Virtual
36. Additional Information*

38. Please provide any additional information that may be useful to our speakers

40. Please email Grants and Public Information with any questions or call (585) 243-7051
    
    

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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

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