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2. DATE*
   DATE
   Today's Date
3. Date and Time of Event*
5. Name of Event*
6. Location of Event*
8. Length of Time Requested of Speaker*
10. Requested Topic*

    1. Career Exploration
    2. Crime Prevention
    3. Gangs

    1. Home/Vehicle Burglary Prevention
    2. Identity Theft/Fraud
    3. Internet Crimes

    1. Kid Safety
    2. Drug Education

    1. Senior Citizen Safety
    2. Women's Safety
12. Other
    Please list request other than those listed above.
14. First Name*
15. Last Name*
17. Phone Number*
18. Address*
20. Email Address*
21. Your Company/Agency
23. Comments or Special Requests
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

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