Mayor's Office for People with Disabilities

Speaker Request Form

Maria Town, Director
Mayor's Office for People with Disabilities
P.O. Box 1562
Houston, TX 77251
Phone Number 832.394.0814
Email: mopdmail@houstontx.gov

PLEASE NOTE ... Requests must be made 15 days in advance and will only be confirmed by the Mayor's Office for People with Disabilities.

ORGANIZATION
   
Org Name:
Org Address 1:
Org Address 2:
Org City:
Org State:
Org ZIP:
Org Phone:
Org FAX:
Org Website:
   
  CONTACT
   
Contact Name:
Contact Address 1:
Contact Address 2:
Contact City:
Contact State:
Contact ZIP:
Contact Phone:
Contact FAX:
Contact E-Mail:
   
  EVENT INFORMATION
   
Event Type:
Event Date:
Day of Week:
Time:
Alt. Dates?:
Event Address:

Include building, floor/room #, and parking instructions


Event Location Phone:
   

Will there be a stage?

Is the stage ramp accessible?

Is there a podium?

What type of mics are available?

Opportunity for the MOPD to staff a resource table at the event?

If yes, please describe your tabling requirements.

Are other City of Houston Officials Invited / Attending? Who?

PRESENTATION INFORMATION
   
Type of Presentation:
Topic of Presentation:
Audience Info:
Time of Presentation:
Length of Presentation:
Group Size: