Special Event Request Form

Title of Event: *

Date of Event*

Organization/Person Hosting Event:*

Location and Physical Address of Event: *

Parking Information for Event:*

Actual Start Time of Event:*

Approximate End Time of Event:*

Contact Person for Event:*

Phone Number: *

Email Address:*

Cell Phone Number (in case of emergency the day of the event):

Nature of Dr. Jones' Appearance:

Brief Remarks

Keynote

Meet and Greet

Other

Suggested subject matter for Dr. Jones' remarks: *

Specific talking points Dr. Jones should include in his remarks:

Anticipated Number of Guests Attending Event:*

Type of Guest Audience (Students, Faculty, Staff, Community, etc.)*

Preferred Length of Dr. Jones' Remarks:

10 minutes

20 minutes

30 minutes [to include Q&A]

Starting Time for Remarks:*

Ending Time for Remarks: *

Microphone Set-Up:

Hand-held

Lapel

Podium

Other

Additional Information Dr. Jones may find helpful when preparing for and/or attending the event:

Print Deadline for Promotional Materials (if applicable):

Promotional Materials Requested:

Photo

Bio

Keynote Title

Other

If other promotional materials are needed, please explain:

If Dr. Jones is unavailable to attend the event, is there an alternate person you would like to request?

Yes

No

If yes, please name: