Executive Commissioner Engagement Request Form

(*= Required Field)

General Information

Name of Organization*

Contact Prefix (Salutation)*

Contact First Name*

Contact Last Name*

Address or P.O. Box*

City*

State*

ZIP code (only 5 digits)*

Contact Email*

Confirm Email*

Phone (only digits)*

Phone Extension (only digits)

Event Information

Event Theme

Event Type*

Event Date*[ 8/21/2019 ]

Event Time (only digits in 24 Hr format)*

Event Address*

Event City*

Event State*

Event ZIP code (only 5 digits)*

Event Purpose*

Event Background/Summary*

Audience Demographic

Event Indoor or Outdoor?*

Expected Number of Attendees

Will there be a Podium?

Will there be a Microphone?

Are the Media Invited?

Media Information*

Title of Person Introducing Executive Commissioner

Name of Person Introducing Executive Commissioner

Any Honoree?

Honoree 1 Name*

Honoree 2 Name

Honoree 1 Spouse or Parent Name

Honoree 2 Spouse or Parent Name

Any Elected Officials?

Title of Attending Elected Official 1

Title of Attending Elected Official 2

Name of Attending Elected Official 1*

Name of Attending Elected Official 2

Day of Engagement

Contact Person for Day of Engagement

Contact Phone Number for Day of Engagement (only digits)

Who will greet the Executive Commissioner on arrival?

Please Provide Parking and Arrival Instructions

Please include any specific information about your organization that you think will be helpful for the Executive Commissioner (background of group, purpose of event, full agenda, 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.