First Name
Last Name
Title:
Organization Name:
Phone number
E-mail
Street Address
City
State/Province
Zip/Postal Code
Event Details
Event Name
Event Sponsor/Organizer
Type or Organization
Please select...
Business
Community Group
Government Organization
Nonprofit
Religious Organization
Other, please specify
Other
Event Start Date & Time
Date
Hour
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
:
Minutes
Please select...
00
10
20
30
40
50
Time of Day
Please select...
AM
PM
Event End Date & Time
Date
Hour
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
:
Minutes
Please select...
00
10
20
30
40
50
Time of Day
Please select...
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
Venue
Please select...
Indoor
Outdoor
Event Type
Please select...
Banquet
Conference
Neighborhood Meeting
Rally
Tour
Other, please specify
Attire
Please select...
Black Tie
Business
Business Casual
Casual
Other, please specify
Event Type (Other)
Attire (Other)
Event Description
Event Size and audience composition
Will media be present?
Please select...
Yes
No
If yes, please specify
Dignitary and community leader invitees (click below to add additional responses)
Dignitary/Community Leader Name
Title/Organzation
Confirmed?
Please select...
Yes
No
Participation Information
What would Tamala McBath's role be at the event?
If Tamala is speaking, what time and for how long?
Time
Time of Day
Please select...
AM
PM
How Long?
Who will introduce Tamala?
Speaking Area
Please select...
Stage
Podium
Other, please specify
Speaking area (other)
What topics would you request Tamala cover in her remarks?
If Tamala is unable to attend, would you accept any of the following (check all that apply):
Video
Staff Representative
Please attach any related event information:
Contact Information