Supervisor Susan Ellenberg Event Appearance Request Form

Event Name

Event Date

Event Time (total)

Event Location & Address (Put "virtual" if an online event)

Role for Supervisor Ellenberg

Event Purpose/Intention

Event Audience Description

Estimated Number of Attendees

Approximate Length of remarks by Supervisor Ellenberg (in minutes, specify if time allotted includes Q&A)

Topic(s) or desired theme of Supervisor Ellenberg's remarks

Agenda/Run of show (Specify whether draft or final)

Parking Information (Put N/A if event is virtual)

Commendation or Certificate Requested?

Event Contact Person Name

Event Contact Person Phone

Event Contact Person Email

Event Url or Website

Additional details (format, run of show, other speakers, whether there is a cost for attendees, etc.)

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