OMB Control Number 3133-0211 Please complete and submit this form to request the NCUA's participation at your upcoming event. Indicates required field Why do you want the NCUA to participate? Section 1: Contact Information Name Title Company/Organization Phone Format: 555-555-5555 Email Address Email Address Confirm Email Address Organization or Event Website/URL Format: http://example.com Information About Your Organization Section 2: Event Information Event Title Event Date Event Date: Year Year202020212022202320242025 Event Date: Month MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Event Date: Day Day12345678910111213141516171819202122232425262728293031 Description Event Address Venue Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Event Format Presentation Seminar Webinar Interview/Fireside Chat Roundtable Speech Workshop Panel Discussion If you selected panel discussion, please provide the panel moderator’s name and organization. If you selected panel discussion, please provide the title of the panel. Event Sponsor Primary Event Sponsor/Host Commercial Entity Nonprofit Academic Institution Government Agency Trade Association Topic Subtopic How long has the event been in existence? First Time 1-2 Years More Than 2 Years Agenda Website/URL Format: http://example.com Invited or Confirmed Speakers (Name and Organization) Other regulator's invited? Yes No If you selected “yes”, please provide the names of the regulators attending. Attending Regulator 1 Attending Regulator 2 Attending Regulator 3 Section 3: About the Audience Target Audience Check all that apply. Credit Union Officials State Supervisory Agency Federal Government Trade Organization Educators Business Leaders Civic Leaders Number of Attendees Confirmation Deadline Confirmation Deadline: Year Year202020212022202320242025 Confirmation Deadline: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Confirmation Deadline: Day Day12345678910111213141516171819202122232425262728293031 Section 4: About the NCUA's Requested Participation Has an NCUA employee ever spoken at your event? Yes No If you answered "Yes" above, please provide name(s) and dates(s) below. Employee Name 1 Employee Date 1 Employee Date 1: Year Year201720182019202020212022202320242025 Employee Date 1: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Employee Date 1: Day Day12345678910111213141516171819202122232425262728293031 Employee Name 2 Employee Date 2 Employee Date 2: Year Year201720182019202020212022202320242025 Employee Date 2: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Employee Date 2: Day Day12345678910111213141516171819202122232425262728293031 Employee Name 3 Employee Date 3 Employee Date 3: Year Year201720182019202020212022202320242025 Employee Date 3: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Employee Date 3: Day Day12345678910111213141516171819202122232425262728293031 Have you contacted an NCUA representative about your event? Yes No If you answered "Yes" above, please provide the representative name(s). Contacted Representative Name 1 Contacted Representative Name 2 Are you requesting a specific NCUA representative? Yes No If you answered "Yes" above, please provide the representative name(s). Requested Representative Name 1 Requested Representative Name 2 Specific Date of Engagement Specific Date of Engagement: Year Year2019202020212022202320242025 Specific Date of Engagement: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Specific Date of Engagement: Day Day12345678910111213141516171819202122232425262728293031 Start Time End Time Speech Duration Is the time slot fixed or tentative? Fixed Tentative Will you provide the NCUA with the audience's feedback? Yes No Will there be a Q&A? Yes No Will the questions be vetted? Yes No If you are requesting the NCUA for more than one speaking engagement, please enter the other sessions' details. Are materials needed? None Presentation Handouts Both Section 5: Media and Event Access Are media representatives invited? Yes No If you answered "Yes" above, please provide the details. Is the event open to the public? Yes No Will the event be recorded, broadcast, or streamed? Yes No If you answered "Yes" above, please provide the website to access the recording or streaming. Format: http://example.com Is it an audio stream or broadcast? Yes No Is it a video stream or broadcast? Yes No If you answered "Yes" to either, how will the recording be purposed? Will there be a photographer onsite for the event? Yes No If you answered "Yes" above, is there a photo approval/release form? Yes No Please provide other relevant or useful information about this event. Terms and Conditions for Requesting a Speaker from the NCUA Submission of this Speaker Request Form is a request only, and does not imply consent to participate by the National Credit Union Administration. The NCUA will consider each request to determine speaker availability and whether participation is in compliance with the laws, rules, regulations and guidelines governing activities of a federal agency and its employees. If the NCUA agrees to participate in the event, confirmation of its participation will be communicated in writing to the contacts provided. The NCUA must review and approve in advance any public announcement, news release, invitation, promotional material or other information to be released regarding an appearance by its employees at the event. The Requester may not use the name of the NCUA in any way that constitutes or implies endorsement of the Requester, the Requester’s Organization, the event, or any participant or topic connected to the event, by the NCUA or its employees. All press participation must be approved at least two weeks prior to the event by the NCUA. If you indicate in the Speaker Request Form that the event is not open to the press and subsequently open the event to the press, the NCUA reserves the right to cancel its participation in the event. The Requester will inform the NCUA if it intends to record or broadcast NCUA employees, or reproduce or distribute any presentations or program material used by NCUA employees in connection with a speech or public appearance. The Requester agrees to cooperate with the NCUA with regard to security arrangements at the event that may be required by the agency. Employees of the NCUA may not accept compensation (including a gift or honorarium) or reimbursement for travel or lodging expenses in connection with this event. The Requester understands and agrees that any material change to the information provided on the Speaker Request Form or any failure to comply with these Terms and Conditions may result in the cancellation of participation in the event by the NCUA and its employees. The NCUA reserves the right to cancel its participation in the event. I agree to the Terms and Conditions specified above for Requesting a Speaker from NCUA Privacy Notice The information you provide will be used to manage the NCUA's participation at events. The NCUA securely maintains all personally identifiable information in its control and only shares it outside of the NCUA if required by law or regulation. For additional information, please contact privacy@ncua.gov. Leave this field blank