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 9/2/2010
   
Enter the code below before submitting the form.
   
Please review the form carefully before submitting.
   
Contact Information
3825 Ridgewood Road
Jackson, Mississippi 39211-6453
Telephone: 601.432.6742


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