Request for Chancellor Appearance

Thank you for completing this form, which will allow the Chancellor to quickly consider your request. The speaking engagement is not confirmed until you receive a separate email with confirmation.

Requestor's Information:

Title Dr. Miss. Mr. Mrs. Ms.

First Name

Last Name

Email Address

Date of Event

Name of Event

Brief Description of Organization and Event

Recommended attire

Start Time

When will the chancellor be called to speak?

End Time

Event Address

Room Name/Number

Parking Arrangements & Specifications

Website

Preferred Length of Speech

Type of Remarks Requested

Order of Events

Speaker to be introduced by

Question and Answer session following speech

Audience Size and Composition

Suggested main points: is there a particular topic that should be addressed? Does the group have any

Check All that Apply

Other Speakers

Key People to Acknowledge in Remarks

Key People to Meet & Greet (include any public and expected officials present, if any)

Phonetic Pronunciation of Names/Key People

On-site Contact Name & Cell Phone Number (example: John Smith 573-555-5555)

Event Contact Person

Contact Phone (example: 573-555-5555)

Form Completed By

Name

Title

Email

Phone (example: 573-555-5555)

Date