Event Scheduling Request

I am pleased to assist constituents of the 17th District of Pennsylvania with their Speech and Appointment Requests. Once your request is received my staff will contact you to verify your request and discuss the appropriate arrangements. Thank you.

Fields with an asterisk(*) are required.

YOUR CONTACT INFORMATION:
*Full Name:**
Organization:
*Address:**
Address2:
*City:**	*State: Zip:* -
*Email:**
Phone:	Fax:
REQUEST FOR CONGRESSMAN TO SPEAK? Yes No
If 'Yes', has Congressman spoken to this group before? Yes No
	If 'Yes', when and about what?
	If surrogate attends, speaking role? Yes No
Time to Speak:	Introduced by:
List Issues to be Addressed:
Other Issues of Inerest to Group:
GENERAL EVENT INFORMATION:
*Event Date:**	*Day of Week:**
Event Time*	From: To:**
	Time Congressman to Arrive:
*Event Name:**
Event Description:
Event Location Name:
*Event Address:**
Event Address2:
*Event City:**	*State: Zip:* -
Event Location Phone:
Media Attending:	Yes No Unknown
Media Outlet:	TV Print Radio
Attire:	Casual Business Cocktail
	Black Tie Other:
Audience Size:
Aud. Description: (profession, age, orgs)
VIPs to Attend:	Yes No If 'Yes', Who?:
CONTACT INFORMATION FOR DAY OF EVENT:
Name:
Phone: (Cell preferred)
ADDITIONAL INFORMATION REQUESTED:
Photo/Biography of Congressman Requested: Yes No
If 'Yes', Send to:
Date Required:
Additional Comments: