Request Form

Organization Requesting Training/Presentation:

Contact Information

Contact Person

Phone

Fax

Mobile

Email

Training/Presentation Information

Date(s)

Time(s)

Location

Subject Matter (please be as descriptive as possible)

# of Presenters

Anticipated Audience (gender, race, age, etc.)

Type of Presenter (gender, race, age, etc.)

Will Battered Women/Advocates Speak
 Yes No

Is this request in Dekalb County?
 Yes No

Special Notes

What is 2+1?
[quiz* quiz-306 "2+1=?|3"]