*
= Required Field
In the event Executive Commissioner Phillips is unavailable for this event, will you consider an alternate speaker?
*
--None--
Yes
No
General Information
Name of Organization
*
Contact Salutation
*
--None--
Dr.
Mr.
Mrs.
Ms.
Contact First Name
*
Contact Last Name
*
Mailing Address
*
City
*
State
*
--None--
TX
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
UT
VA
VI
VT
WA
WI
WV
WY
Zip code
*
Contact Email
*
Confirm Email
*
Phone (only digits)
*
Phone Extension (only digits)
Event Information
Title
Type
*
--None--
Meeting Request
Speaking Engagement
Date (must be 3 days after today)
*
[
12/11/2019
]
Time (12 Hr format and specify AM/PM)
*
Address
*
City
*
State
*
--None--
TX
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
UT
VA
VI
VT
WA
WI
WV
WY
Zip code
*
Purpose
*
Audience Demographic
Expected Number of Attendees
Venue
*
--None--
Indoor
Outdoor
Will there be a Podium?
--None--
Yes
No
Will there be a Microphone?
--None--
Yes
No
Are the Media Invited?
*
--None--
Yes
No
Unknown
Media Information
*
Person Introducing Executive Commissioner Phillips
Title of Person Introducing Executive Commissioner Phillips
Format
--None--
Panel
Keynote Speaker
Have Panelists been confirmed?
--None--
Yes
No
Panelists
Other Special Guests
--None--
Yes
No
Special Guest Type
--None--
Honoree
Elected Official
Other
Is Special Guest confirmed?
--None--
Yes
No
Special Guest Name and Affiliation
Other Details
*
Honoree 1
*
Honoree 2
Elected Official 1
*
Elected Official 2
Date of Engagement
Contact Person on Date of Engagement
Contact Person's Phone Number on Date of Engagement (only digits)
Who will greet Executive Commissioner Phillips on arrival?
Please Provide Parking and Arrival Instructions
Please include any specific information about your organization and the event that you think will be helpful for Executive Commissioner Phillips (full agenda, talking points, etc.)
*
By checking this box, I certify and acknowledge that any information entered into this form is for the HHS Executive Commissioner engagement and/or meeting request only.