Request Representative for Your Event

Council/Assembly Name
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Requestor's Name(*)
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Requestor's Phone (xxx) xxx-xxxx
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Requestor's Email(*)
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Event Type/Name(*)
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Location (Name & Address)
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Attire Requested
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Would you like the State Council Rep to Speak?
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If Yes, do you have a specific topic you would like addressed?
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Council/Assembly Number
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Date of Event

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Time of Event
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Requested Reply by Date

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We want to make sure that a real person is ending the form. Please enter the character you see.(*)
We want to make sure that a real person is ending the form. Please enter the character you see.
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