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‚ÄčSpeaking Request Form 
If you would like DHHS CEO, Courtney Phillips to speak at your event, please complete and submit the form below. 
Event Name:
Preferred Date and Time:
Contact Name:
Contact Email Address:
Contact person for day of engagement:
Contact phone for day of engagement:(XXX-XXX-XXXX)
Suggested length of speech (including any Q&A):
Specific topics suggested for discussion:
Name, Title of person introducing the CEO:
Approximate size of audience:
Audience Demographic:
Honoree names:
Honoree spouse or parent name:
Name, title of attending elected officials:
Are the media invited?:
Will there be a podium and microphone?:
Do you have PowerPoint Presentation capabilities?:
Please provide parking and arrival instructions:
Who will greet the CEO on arrival?:
Please include any specific information about your organization that you think will be helpful for the CEO (background of group, purpose of event, full agenda, etc.)

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