If you would like to make a request for the Governor to attend or speak at an event, please fill out the following request form and be sure to fill in each of the blanks on this form. After you have filled in all of the information, click on the ‘Submit’ button and you will receive an e-mail confirming that your request has been received by the Governor’s office. Please submit your scheduling request for an event that is at least two weeks from today’s date. Thank you.

Contact Information
          *Prefix *First Name *Last Name  
*Home Phone *Work Phone *Email  

Speech/Event Information
            *Name of Event 
*Speech Topic
*Request Type
*Date of Event 
*Day of Week
Speaking Time  
Speech Length
Name of Person Introducing the Governor  
Other Speakers 

           *Event Begin Time *Event End Time *Inside or Outside
*Location Event  
*Name of Facility  
*Facility Address  
*Directions to Facility From Nearest Airport’  
*Name of Group or Sponsor Organization  
*Contact Person 1  
*Contact Person 2
*Emergency Cell Phone Number  

*Estimated Attendance  
Media Attending  

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Governor Haley Barbour
P.O. Box 139 Jackson, MS 39205
Phone: 601.359.3150 Fax: 601.359.3741