Rep. Pohutsky's Meeting Request Form

First Name *

Last Name *

Phone Number *

Email *

Organization Name

Type of Event *

In Person

Virtual

Either In Person or Virtual

Event Date Requested *

Open Request (No Specific Date Requested)

Request has a beginning and ending Date

Start Date and Time

End Date and Time

Starting Date *

Starting Time *

Ending Date *

Ending Time *

Expected Number of Attendees *

Has the Representative spoken to this group previously? If so, where and when? *

Event Location/Address *

City *

State *

ZIP *

Is this event Indoor or Outdoor *

Indoors

Outdoors

Is this event open to the public *

Yes

No

Is this event open to the Media *

Yes

No

Notable Attendees

Background/Notes/Any other information we should know?

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

Rep. Pohutsky’s Meeting Request Form