Dr. Corey A. Jackson District 60 You must have JavaScript enabled to use this form. Form Type Selection Fieldset Form Type Meeting Request Event Request Meeting Request To schedule a meeting, please submit the following scheduling request form. Due to the large volume of requests, please allow 5 business days before following up on the requests. Event Request To schedule an event, please submit the following scheduling request form. Due to the large volume of requests, please allow 5 business days before following up on the requests. Contact Information Name of Organization Contact Composite Contact Composite First Name MI? Last Name Email Address Address Address 2 City State - Select -ALAKAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Zip+4 Phone (Mobile) Daytime Phone Evening Phone Fax Meeting Request Form Meeting Topic & Attendees Topic/Purpose of Meeting Bill Number Include Bill Type (AB or SB) Issue to be Discussed Position Support Oppose None Attendees Attendees Attendees Name Title Represents Attendee is Constituent Constituent Address Meeting Date/Time & Location Meeting Date Time Meeting Date Time: Date Meeting Date Time: Time Flexible Date/Time is open for change or contains multiple dates Additional Dates Preferred Location of Meeting Capitol Office District Office Virtual Meeting Other Preferred District Office Web Address Provide a meeting address link (Zoom, Teams, etc.) Other Location Information Description of Other Location Address Address 2 City Attach Background Information? Info, Agendas, Speaking Points etc. Browse File Additional Comments Event Request Form Event Date/Time Event Start Date/Time Event Start Date/Time: Date Event Start Date/Time: Time Event End Date/Time Event End Date/Time: Date Event End Date/Time: Time Flexible Date/Time is open for change or contains multiple dates Additional Dates Event Location Indoors or Outdoors? Indoors Outdoors Virtual Address Address 2 City State - Select -ALAKAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Zip+4 Location Details Details about the venue, parking, and/or anything related. Speaking Engagement Event Title The name of the event. Dress Attire Business Casual Formal How long will the Assemblymember be speaking or participating? Subject Matter to be Addressed and/or the Assemblymember's role Will there be other speakers? Yes No Event Other Speakers List Event Other Speakers List Name Title Confirmed Yes No Event Logistics Will there be a Q&A? Yes No Has the media been invited to attend? Yes No Attach Background Information? Browse File Attachment is pertinent to the request. Approximate Attendees Additional Comments Submission Information Submission Information I am submitting this request on behalf of someone Name of person Submission Fieldset CAPTCHA Hidden Elements District ID Sponsorship Opportunity Microphone & Podium Will Any Other Elected Officials be in Attendance? Yes No Type of Remarks Welcome Keynote Panel Congratulatory Short Remarks Q&A Staff Assigned Assemblymember Greeted By Assemblymember Introduced By Assemblymember Sitting With Leave this field blank
