Your Name*:

Address*:

City*:

State*:

Zip*:

Day-time Phone*:

E-mail Address*:

Date of Event*:

Time of Event - Beginning*:

Time of Event - Ending*:

Name of Group Sponsoring Event*:

Sponsor's Contact Name:

Sponsor's Day-time Phone:

Type of Event*:

Describe Event*:

Event Location*:

What role do you want the Lieutenant Governor to play in this event?*
(greeting, keynote, short comments, etc.)

Number of Attendees Expected:

Media Invited*: Yes No

Type of Media*: Print Radio Television None

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