Congressman Patrick J. Tiberi

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Please provide the following information to request the Congressman attend your event. You will be contacted on or before your requested confirmation date. Please note, this form does not confirm the Congressman's attendance at your event. If you have any questions, please contact our office at 614-523-2555. Thank you for your interest and cooperation.

Name of Organization

Address of the Event

(If appointment is accepted, you will need to provide written directions to the event)

Contact Name:

Contact Telephone:

Contact Cellular/Pager:

Contact Fax:

Contact Email:

Alternate Contact Name:

Alternate Telephone:

Alternate Cellular/Pager:

Alternate Fax:

Alternate Email:

Person Meeting Pat at the Event:

Location of Meeting Place:

Name of Event:

Date of Event

Month

Day

Year

Time of Event

Dress Code
(Business, Formal, Bus. Casual, Casual)

Number of Attendees:

Requested Role for Representative Tiberi:

Confirmation Date:
(i.e., the date by which you must receive a response)

Speech:

Yes No

Duration of Speech:

Begin Time:
End Time:

Q & A Segment:

Yes No

Time Alotted:

Location of Event:
(Please include city)

Topic(s) of Interest:

Who is Audience:

Invited Expected to attend

Representative Tiberi Introduced by:

Individuals/Organization(s) to recognize:

Other Speakers:

VIP/Elected Officials Attending:

Press Expected to Attend:

Yes No

Podium:

Yes No

Is this a Fundraising Event:

Yes No