Scheduling Request Please complete the form below to send a scheduling request to the Governor. Fields marked with an asterisk (*) are required. Note: filling out the request does not guarantee the Governor’s participation. Requestor Name * Requestor Email * Requestor Cell Number * Please format as XXX-XXX-XXXX Requestor Office Number * Please format as XXX-XXX-XXXX Type of Invitation / Request * Meeting Event Meeting Form Requestor Company/Organization * Meeting Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Meeting Purpose * Meeting Attendees * Are you willing to meet with staff if Governor is not available? * Yes No Event Form Event Description Event Name * Host Organization * Event Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Event Start Time * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Event End Time * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Event Location * What is the venue name? Indoor/Outdoor * Indoor Outdoor Street Address * City * Zip Code * County * - Select -AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyNot Applicable Contact Person at Event - Same as Requestor * Yes No Day of Contact Name * Day of Contact Email * Day of Contact Cell Number * Please format as XXX-XXX-XXXX Type of Event * Annual Meeting Conference Press Conference Tour Other - please describe Other Type of Event Estimated Number of Attendees * Audience Description * Dignitaries Attending * Elected officials, company officials, other dignitaries – please list name and titles. Is event open to public? * Yes No Do you plan to invite media? * Yes No Purpose of Governor’s Role What is Governor's level of participation? * Speak Attend Other - please explain Other Level of Participation * Time and Duration of Remarks * Speaking Format * Keynote Brief Remarks Roundtable Other - please explain Other Speaking Format * Who will introduce Governor? * List other speakers and order in which they will speak * Name, title & topic, if known. Please separate speakers with a semi-colon. Are you willing to have staff or another member of the administration participate if Governor is unable to attend? * Yes No Any additional information you wish to share Supporting Material Supporting material such as an invitation, program or biographies can be emailed to scheduling@nc.gov. Please indicate the name and date of your event in the subject line. Are you requesting a letter from the Governor to be placed in your program/souvenir book? Yes No If yes, please provide a date the letter is needed for printing Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021
