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indicates required fields
Name of Event
*
Date of Event
*
-
Month
-
Day
Year
Date Picker Icon
Requesting Organization
*
Location
*
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
End Time
*
Hour Minutes
AM
PM
AM/PM Option
Brief Background on Event (including activity, purpose and strategy)
*
Please provide agenda/tentative schedule (if available)
Will the news media be present?
Yes
No
Audience Size
*
Audience Profile
*
Please list whether the audience is internal, external, business, education, government, donors, etc. (Provide names of guests you may want to introduce to the President if time permits.)
Do you want the president to speak at your event?
*
Yes
No (Attend Only)
Speech Information
If you are requesting the President to speak at your event, we will need all pertinent information, at minimum, 2 weeks in advance.
Which of the following would you like the president to participate in?
Welcome
Keynote
Remarks
Panelist
Q&A Session
Other
Describe the topic, subject, and suggested talking points
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How many minutes does he have to speak?
*
Who will introduce the President?
*
President's Role
*
Please explain if you expect the President to attend for the duration of the event, or if it is a shorter visit.
Contact Information
Name
*
First Name
Last Name
Company/Organization
*
Title
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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