Complete and submit this form to request Congressman Carson to speak at your event. Due to the Member's schedule, not all requests will be filled. * marks required fields of data. Primary ContactName: Name: * Last Name: * Title: * Organization Name: Street Address: City/State/Zip: City * State * Zip Code * Method of Contact: Email telephone Event Information: Event Name: * Event Sponsor/Organizer: * Type of Organization: * Organization TypeBusinessCommunity GroupGovernment OrganizationNonprofitReligious OrganizationOther, Please Specify If other, please specify: Event Start Date & Time:(e.g. 2:00 PM) Start date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Start time: Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Event End Date & Time:(e.g. 2:00 PM) End date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 end time Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Full Event Address * Additional Information: For example: table number and location, name of building, location within a park). * Event Venue/Event Type/Event Attire/: select_venue * Must Select VenueIndoorOutdoorOther, please specify select event type * Must Select Event TypeBanquetConferenceNeighborhood MeetingRallyTourOther, please specify select event attire * Must Select Event AttireBlack TieBusinessBusiness CasualCasualOther, please specify Other Event Type/Other Event Attire: Other Event Type Other Event Attire Event Description: * Event size and audience composition (i.e. 20 high school graduates): * Will media be present: media_present * YesNo media yes specify List dignitaries and community leaders invited to event:Dignitary/Community Leader Dignitary Name * Dignitary title * dignitary confirmed * Confirmed?YesNo Dignitary/Community Leader Dignitary Name Dignitary title dignitary confirmed Confirmed?YesNo Dignitary/Community Leader Dignitary Name Dignitary title dignitary confirmed Confirmed?YesNo Dignitary/Community Leader Dignitary Name Dignitary title dignitary confirmed Confirmed?YesNo Participation Information: What would the Congressman's role be at the event? * If the Congressman is speaking, what time and for how long?: speech time * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm speech length Who will introduce the Congressman? * Speaking Area: Speaking Area * - Select -StagePodiumOther, please specify speak area other What topics would you request the Congressman covers in his remarks? * Program Information:Would you like a congressional greeting for your program? If yes, what is the printing deadline for the program? greeting YesNo greeting time * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Will there be any awards presented as part of the program? (If so, please list specific details) * List the formal program/schedule for your event: * If the Congressman is unavailable to attend, would you accept any of the following: (check all that apply) unavail_option Video Staff Representative Congressional Greeting If you are requesting a staff representative: Will you acknowledge the representative? YesNo May staff deliver remarks or read a Congressional greeting? YesNo CAPTCHA
