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Name of Organization
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Name of Event:
Date of Event
Month
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Day
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Year
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2011
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2014
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2020
Time of Event
A.M.
P.M.
Dress Code
Number of Attendees:
Requested Role for Representative Gingrey:
Contact Name:
Contact Telephone:
Contact Cellular/Pager:
Contact Fax:
Contact Email:
Alternate Contact Name:
Alternate Telephone:
Alternate Cellular/Pager:
Alternate Fax:
Alternate Email:
Speech:
Yes
No
Duration of Speech:
Begin Time:
A.M.
P.M.
End Time:
A.M.
P.M.
Location of Speech:
Topic(s) of Interest:
Representative Gingrey Introduced by:
Individuals/Organization(s) to recognize:
Other Speakers:
Press Expected to Attend:
Yes
No
Podium:
Yes
No
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