Speaker Data Request Form

If you would be interested in adding your name to the District 11 Public Affairs Speaker Database, please submit the following form.

The database is used by the Public Affairs Office to quickly match appropriate speakers to requests. By submitting this information, you are under no obligation to fulfill any or all requests that might be submitted to you. Information submitted is retained by the District 11 Public Affairs Office for the sole purpose of the speaker database. If you have any questions regarding this form or any other public affairs issues, please call us at (510) 437-3325.

NAME:
DATE:
UNIT:
WHAT IS YOUR EXPECTED ROTATION DATE FROM YOUR CURRENT UNIT?
RATE/RANK:
TITLE:
PHONE:
E-MAIL:
SEX:
MALE
FEMALE
AGE (OPTIONAL):
WHERE DO YOU LIVE (CITY):
DO YOU HAVE PUBLIC SPEAKING EXPERIENCE OR FORMAL TRAINING IN PUBLIC SPEAKING?
YES
NO
IF YES, WHERE AND WHEN?
ARE YOU WILLING TO TRAVEL TO SPEAKING ENGAGEMENTS (EXPENSES MAY NOT BE REIMBURSABLE)?
YES
NO
IF YES, HOW FAR
ARE YOU WILLING TO SPEAK AFTER REGULAR WORK HOURS?
YES
NO
IF YES, PLEASE SPECIFY:
EVENINGS
WEEKENDS
BOTH
WHICH MISSION AREA(S) DO YOU HAVE KNOWLEDGE AND EXPERIENCE IN? (SELECT ALL THAT APPLY)
HOMELAND SECURITY
BOATING SAFETY
SEARCH AND RESCUE
LAW ENFORCEMENT
MARINE ENVIRONMENTAL PROTECTION
SUBJECTS YOU ARE WILLING TO DISCUSS, IN ORDER OF PREFERENCE, AND TRAINING/EXPERIENCE IN AREA.
LIST ANY PREFERENCES YOU MAY HAVE REGARDING SPEAKING ENGAGEMENTS:
LIST CIVIC AND/OR SERVICE ORGANIZATIONS IN WHICH YOU HAVE HELD A MEMBERSHIP:
PLEASE TELL US ANY OTHER INFORMATION THAT MIGHT BE USEFUL IN MATCHING YOU TO A SPECIFIED REQUEST. LET US KNOW ANY RESERVATIONS YOU MIGHT HAVE.

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