Chancellor Meeting or Event Speaking Request Form

First Name *

Last Name *

Title

Host/organizational name

Has the Chancellor addressed this group or organization in the past?

Yes
No

If "yes", please provide the date and name of the event.

If other, please specify.

Email *

Best contact phone # *

Organization website

Event Information

If requestor will not be at the event, please provide the name of an on-site contact.

First Name

Last Name

Phone Number of on-site contact:

Type of event

In-person
Virtual
Pre-recorded
Hybrid

Livestream/Zoom information

Event name

Event Date

Event Start Time

Event End Time

Event location address (address, building, room)

Street Address

Address Line 2

City

State / Province / Region

Country

Event parking location

Requested arrival and departure time for the Chancellor

If other, please specify.

Expected number of attendees

Distinguished guests also attending

Elected officials also attending

Information for Speaking Events

Who will introduce the Chancellor? (name, title and brief bio)

If other, please specify.

Requested topics/talking points for remarks

If other, please specify.

Will the event be recorded?

Yes
No

Will the event be broadcast?

Yes
No

Will a photographer be present?

Yes
No

Is media invited?

Yes
No

Attachments and Additional Information

Please attach any agendas, event programs, host/organization or event background materials, confirmed guest lists, table/ seating arrangements and names of guests at the Chancellor's table, an event invitation (please submit for review before publication/distribution when listing the Chancellor). Max. files: 1 (multiple files can be uploaded as a .zip file).

Please complete

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