Rep. Herzberg'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?

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Rep. Herzberg’s Meeting Request Form