LEAP - Speaker Request Form

Speaker Request Form

Please fill out the following form to request a LEAP speaker for your club meeting or upcoming event. A LEAP representative will contact you to confirm the invitation and discuss details.
Grey items are optional.

Your First Name:
Your Last Name:
Your Email Address:
Your Phone Number:

Sponsoring Club or Organization:
Club Mailing Address:
City:
State/Province:
Country:
Zip/Postal Code:

Event Type:
Event Access:	Closed to the media Closed to the public
Event Title:
Event Location:
Proposed Date:
Proposed Time:
Event Description/Details: (including time allotted for speaker)

Anticipated Attendance:
Event Or Club Website:

Dedicated to our departed colleagues who courageously spoke out about the destructive policy of Drug Prohibition
Jerry Paradis	Eleanor Schockett	Gil Puder	Whitman Knapp	John Perry	Ralph Salerno	Bob Owens	Eddie Ellison	Martin Haines