Speaker Request Form

Speaker Request Form
Please complete and submit this form to request the NCUA's participation at your upcoming event.
Indicates required field
Why do you want the NCUA to
participate?

Section 1: Contact Information
Name
Title
Company/Organization
Phone
Format: 555-555-5555
Email Address
Confirm Email Address

Organization or Event Website/URL
Format: http://example.com
Information About Your Organization

Section 2: Event Information
Event Title
Event Date
Year

  Month

Description
Venue Address
City

  Day

State
- None -

Country
- None -

Event Format
 Presentation
 Seminar
 Webinar
 Interview/Fireside Chat
 Roundtable
 Speech
 Workshop
 Panel Discussion
If you selected panel discussion,
please provide the panel moderator’s
name and organization.
If you selected panel discussion,
please provide the title of the panel.
Event Sponsor
Primary Event Sponsor/Host
 Commercial Entity
 Nonprofit
 Academic Institution
 Government Agency
 Trade Association
Topic
Subtopic
How long has the event been in existence?

 First Time
 1-2 Years
 More Than 2 Years
Agenda Website/URL

Format: http://example.com
Invited or Confirmed Speakers (Name
and Organization)

Other regulator's invited?

 Yes
 No
If you selected “yes”, please provide the names of the regulators attending.
Attending Regulator 1
Attending Regulator 2
Attending Regulator 3

Section 3: About the Audience
Target Audience

Check all that apply.

 Credit Union Officials
 State Supervisory Agency
 Federal Government
 Trade Organization
 Educators
 Business Leaders
 Civic Leaders
Number of Attendees
Confirmation Deadline
Year

  Month

  Day

Section 4: About the NCUA's Requested Participation
Has an NCUA employee ever spoken at your event?

 Yes
 No

If you answered "Yes" above, please provide name(s) and dates(s) below.
Employee Name 1
Employee Date 1
Year

  Month

  Day

Employee Name 2
Employee Date 2
Year

  Month

  Day

Employee Name 3
Employee Date 3
Year

  Month

  Day

Have you contacted an NCUA representative about your event?

 Yes
 No
If you answered "Yes" above, please provide the representative name(s).
Contacted Representative Name 1
Contacted Representative Name 2
Are you requesting a specific NCUA representative?

 Yes
 No
If you answered "Yes" above, please provide the representative name(s).
Requested Representative Name 1
Requested Representative Name 2
Specific Date of Engagement
Year

  Month

Start Time
--:-- --

End Time
--:-- --

Speech Duration

  Day

Is the time slot fixed or tentative?

 Fixed
 Tentative
Will you provide the NCUA with the audience's feedback?

 Yes
 No
Will there be a Q&A?

 Yes
 No
Will the questions be vetted?

 Yes
 No
If you are requesting the NCUA for
more than one speaking engagement,
please enter the other sessions'
details.

Are materials needed?

 None
 Presentation
 Handouts
 Both

Section 5: Media and Event Access
Are media representatives invited?

 Yes
 No
If you answered "Yes" above, please
provide the details.

Is the event open to the public?

 Yes
 No
Will the event be recorded, broadcast, or streamed?

 Yes
 No
If you answered "Yes" above, please
provide the website to access the
recording or streaming.
Format: http://example.com
Is it an audio stream or broadcast?

 Yes
 No
Is it a video stream or broadcast?

 Yes
 No
If you answered "Yes" to either, how
will the recording be purposed?
Will there be a photographer onsite for the event?

 Yes
 No
If you answered "Yes" above, is there a photo approval/release form?

 Yes
 No
Please provide other relevant or
useful information about this event.

Terms and Conditions for Requesting a Speaker from the NCUA
1. Submission of this Speaker Request Form is a request only, and does not imply consent to participate by the National Credit
Union Administration. The NCUA will consider each request to determine speaker availability and whether participation is in
compliance with the laws, rules, regulations and guidelines governing activities of a federal agency and its employees. If the
NCUA agrees to participate in the event, confirmation of its participation will be communicated in writing to the contacts provided.

2. The NCUA must review and approve in advance any public announcement, news release, invitation, promotional material or
other information to be released regarding an appearance by its employees at the event. The Requester may not use the name
of the NCUA in any way that constitutes or implies endorsement of the Requester, the Requester’s Organization, the event, or
any participant or topic connected to the event, by the NCUA or its employees.
3. All press participation must be approved at least two weeks prior to the event by the NCUA. If you indicate in the Speaker
Request Form that the event is not open to the press and subsequently open the event to the press, the NCUA reserves the right
to cancel its participation in the event.
4. The Requester will inform the NCUA if it intends to record or broadcast NCUA employees, or reproduce or distribute any
presentations or program material used by NCUA employees in connection with a speech or public appearance.
5. The Requester agrees to cooperate with the NCUA with regard to security arrangements at the event that may be required by the
agency.
6. Employees of the NCUA may not accept compensation (including a gift or honorarium) or reimbursement for travel or lodging
expenses in connection with this event.
7. The Requester understands and agrees that any material change to the information provided on the Speaker Request Form or
any failure to comply with these Terms and Conditions may result in the cancellation of participation in the event by the NCUA
and its employees. The NCUA reserves the right to  cancel its participation in the event.

 I agree to the Terms and Conditions specified above for Requesting a Speaker from NCUA
Privacy Notice
The information you provide will be used to manage the NCUA's participation at events. The NCUA securely maintains all personally
identifiable information in its control and only shares it outside of the NCUA if required by law or regulation. For additional information,
please contact privacy@ncua.gov.
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