1. Requesting Agency's Information

Requester's First Name*:

Requester's Last Name*:

Position*:

Agency/Organization*:

Department:

Agency Type*:

---State GovernmentLocal GovernmentTribal GovernmentOther

OJJDP Grantee?*

---YesNoUnsure

Address*:

Phone Number*:

Cellphone Number:

Fax Number:

E-mail Address*:

2. Conference Information

Conference Name*:

Start Date*:

End Date*:

Location*:

Host Agency/Organization:

Point of Contact:

Title:

Address:

Phone Number:

Cellphone Number:

Fax Number:

E-mail Address:

3. Conference Costs

Conference Cost (What is the cost to attend the conference, if any?):

4. Assistance Request Type

What type of conference assistance are you requesting?*

---Speaker/Presenter AssistanceLogistical SupportCurriculum/Agenda Development

4a. Speaker/Presenter Assistance Information

Please provide the following information if requesting speaker/presenter assistance for your conference support.

First Name:

Last Name:

Title:

Agency/Organization:

Address:

Phone Number:

Cellphone Number:

Fax Number:

E-mail Address:

Session Title:

Session Date:

Session Length:

6. Special Considerations

Describe the specific outcomes you hope to achieve through the conference.

5. Outcomes

Are there any time constraints, issues, or special considerations that need to be taken into consideration with this request (e.g. time constants due to local agency work/availability schedules)?