Mississippi Public Universities - Data Management & Institutional Research

Institutional Research

Event Information Form

Thank you for your interest. The following information is needed for scheduling purposes. Please return form to: Research and Planning, Mississippi Institutions of Higher Learning, 3825 Ridgewood Road, Jackson, MS 39205 or fax to: 601-432-6117, phone: 601-432-6742, email: dbridges@mississippi.edu

Event Date

Beginning Time

Requested Speaker

Speaking Time

Ending Time

Name of the Event

Location of the Event

Address of the Event

Estimated Attendance

Target Audience

Sponsoring Group or Organization

Contact Person and Title

Phone Number

Fax Number

Email Address

Contact Person at the Event

"In Case of Emergency" Number at Event Location

Directions to Event from the Paul B. Johnson Tower Building

Approximate driving time from Jackson

Type of Request

Appearance Only

Keynote Address

Welcome/Opening Remarks

Brief Address

Panel Participant

Other

For Speaking Engagements

Length of Speech

Topic of Interest for Speech or Remarks

Questions and Answer Time Requested and Length

Vita or Photo Requested

Vita

Photo

Name and Title of Person Making Introduction

Other Speakers

Submission Date

5/16/2012

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Please review the form carefully before submitting.



	© 2012 Mississippi Institutions of Higher Learning 3825 Ridgewood Road Jackson, MS 39211