Mississippi Public Universities
Institutional Research
Event Information Form

Thank you for your interest. The following information is needed for scheduling purposes. Please return form to: University Research Center, Mississippi Institutions of Higher Learning, 3825 Ridgewood Road, Jackson, MS 39205 or fax to: 601-432-6117, phone: 601-432-6742, email: jtaylor@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
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 9/23/2017
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Please review the form carefully before submitting.