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2. Referendum Speakers Bureau Information
4. Name*
6. Department*
8. Email*
10. Cell Phone*
11. Alt. Phone*
13. Groups*

    Groups you are a member of or assiciated with (i.e. Goochland Rotary, Goochland Pet Lovers):

15. Avoid Dates (Sept. 6 - Oct. 31)*

    (i.e. Wednesdays, or Sept. 16 - 18)

Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit

* indicates a required field