Please complete the following information to request a speaker from the Office of the Kansas Securities Commissioner. Request subject to availability.

Event Date:

Event Time:

Number Attending:

Group or Organization:

Contact Information:

Name:

Email:

Phone:

Cell Phone:

Fax:

Event Information:

Event Name:

Address:

City:

State:

Zip:

Contact at Event:

Phone:

Is the event open to the public?

No

Yes

Will a meal be served?

No

Yes

Is this a request for the Commissioner only?

No

Yes

If the Commissioner is not available, would another agency representative be OK?

No

Yes

Special Directions to the Event:

Type of Appearance:

Appearance Only: Brief Remarks: Keynote Speaker:

Drop by: Welcome:

Exact Speaking Time:

Time Allowed for Speech:

Q&A Time:

Our office has several presentations available for the public. Please select one of the following topics:

Outsmarting Investment Fraud Women and Investing Capital Formation

For Industry Professionals- Registration Filings & Disclosures For Industry Professionals: Creating Effective Compliance Systems & Practices For Industry Professionals: Administrative Enforcement and Procedures

Other Speakers:

Who Introduces?

Who will greet the Commissioner or speaker?

Attire:

Is there an LCD Projector, Screen and Laptop Available?

Yes

No

Media Contact:

Bio requested?

Yes

No

Additional Information: