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 characters you see.(*)
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Silent Auction Items

  • Silent Auction Item 1
    Silent Auction Item 1

    Aberlour Scotch Whiskey
    Donated By: 
    Value: $100.00

  • Silent Auction Item 2
    Silent Auction Item 2

    Diffuser Set
    Value $25

  • Silent Auction Item 3
    Silent Auction Item 3

    Wine/Chocolate/Snack Basket
    Value $35

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