Scheduling Request

Please complete the following information to request the Lt. Governor to attend your event. All fields marked with an asterisk () are required and must be completed.

Event Information

Name of Event:

Group or Organization:

Event Date:

Beginning Time:

End Time:

Location of Event:

Room Name or Number:

Address:

City:

State:

Zip: (ex. XXXXX)

Approximate Number of Attendees:

Appearance Information

Participation:
(Choose Only One)

What Time Would You Like the Lt. Governor To Arrive?

What Time Would You Like the Lt. Governor To Speak?

Speech Topic:

Speech Length:

Is the Event Open to the Public?

Yes No

Will There be a Q & A?

Yes No

Will a Meal be Served?

Yes No

Appropriate Event Attire:

Other Speakers/Dignitaries to Attend Event:

Contact Information

First Name:

Last Name:

Contact Email:

Contact Phone Number: (ex. XXX-XXX-XXXX)

Contact Cell Phone Number: (ex. XXX-XXX-XXXX or N/A)

Contact Fax Number: (ex. XXX-XXX-XXXX)

Bio Requested?
(Also available here)

Yes No

Photo Requested?
(Also available here)

Yes No

Additional Information: