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 Host Organization * Event Name * Event Summary * Please provide a brief summary of the event 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 Letter Fieldset If yes, please provide a name and mailing address for the letter, as well as the date the letter is needed for printing. Letter Name * Letter Address 1 * Letter Address 2 Letter City * Letter State * Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Letter Zip Code * Date the letter is needed for printing * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021
