IUPUI

Name:

Phone:

E-mail:

Fax:

Name of Event:

Date of Event:

Time of Event:

Location of Event:

Purpose of Event:

If you checked attendance only, you may skip to the bottom and submit this form.

If you checked participation, please take a moment to complete the rest of this form:

Describe the exact nature of the role the chancellor is expected to play (check all that apply) and indicate the total length of time you wish him to speak:

Remarks
Introductions
Keynote Address
Panelist
Informal Discussion
Interview or Q&A
Master of Ceremonies
Award Presentation
Other (please describe)

Length of Time Requested:

5 minutes or less 5-10 minutes 10-20 minutes Other

Is a podium available?

Is a microphone available?

List the order of speakers or describe the flow of events, indicating the approximate time the chancellor's part in the program begins and ends:

Who will introduce the chancellor?

Is the chancellor free to leave after his remarks?

Should he plan to stay for the entire event, if possible?

Is his wife, Dr. Sandra Petronio, to be included in your invitation for this event?

Please list other members of the campus administration who will be invited to attend.

Please include background materials (e.g., bios, speaker's notes, description of your organization, etc).

When available, please send the offical invitation to the event, printed programs, and confirmed guest list.

Function Atmosphere (and dress):

Business Casual Formal (Black Tie) Other

Number of Attendees Expected:

Nature of Audience (check all that apply):

Students
Faculty
Staff
Alumni
Campus
University
Community
Elected Officials
Members of Your Organization Only