Your Name (required)

Your Email (required)

Your Phone No: (required)

Name of PES Chapter**

PES Chapter Address

PES Chapter Website

PES Chapter Social Media (if any)

Additional PES Chapter"(s)" involved (if any)

Reason for choice of the PES DL Speaker

Reason for this PES DLP Activity

Speaker

Proposed PES DLP Date(s)

Preferred Topic

Estimated Online Attendance (if web-streaming)