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2. Contact Information
4. First Name*
5. Last Name*
7. Phone Number*
8. E-Mail Address*
10. Presentation Request Information
12. Date*
    Date
13. From*
    From
14. To*
    To
16. What topics are most important to your group?
    Check all that apply.

    1. General Presentation/ Public Speaking Event
    2. Church Safety Presentation
    3. Target Hardening/ CPTED (Crime Prevention Through Environmental Design)
    4. Group Tour of Police Department
    5. Student Career Day
    6. Recruiting Job Fair
    7. Public Appearance
    8. Other (Please explain in comments below.)
18. Comments
20. Name of Location/Group*
22. Address1*
24. Address2
26. City
27. State
28. Zip
30. About Your Group
32. What is the age range in your group?*

    1. Children 6 years and younger
    2. Children 7-12 years old
    3. Children 13-18 years old
    4. Adults 18 and above
    5. Seniors
34. This is a request and does not guarantee the date/time selected. An email will be sent to you confirming your request for a presentation. Thank you!
36. Additional Comments
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field