If you would like to invite Representative Burrell to attend or speak at your event, please complete the scheduling request form below. All fields must be complete. To print the scheduling request form, click here.

Name of Organization:

Address of the Event:

Name of Event:

Date of Event: Time of Event: a.m. p.m.

Dress Code:

Number of Attendees:

Requested Role for Representative Burrell:

Contact Name:

Contact Telephone:

Contact Cellular/Pager:

Contact Fax:

Contact E-mail:

Alternate Contact Name:

Alternate Telephone:

Alternate Cellular/Pager:

Alternate Fax:

Alternate E-mail:

Speech (please choose one): Yes No Duration of Speech:

Location of Speech:

Topic(s) of Speech (please explain in detail):

Representative Burrell Introduced by:

Individuals/Organization(s) to recognize:

Other Speakers:

Press Expected to Attend: Yes No

Podium: Yes No