IPR Speaker Request Form
Company Name:

Company Address

Street Line 1:
Street Line 2:
City:
State/Province:
Zip/Postal Code:

Point of Contact Information

First Name:
Last Name:
Phone:
FAX:
Email:

Event Information

Event Description and Discussion Topic:	Please enter a brief description of the event - please include discussion topic
Event Date:
Street Line 1:
Street Line 2:
City:
State/Province:
Zip/Postal Code:
Event Format	Individual Panel
Length of Presentation:

For additional information please contact us at:

U.S. Customs and Border Protection
IPR Policy Branch
Sebastian G. Wright, Chief
Phone:	(202) 863-6259
Email:	Sebastian.G.Wright@dhs.gov