Engagement Request Form - University of Arkansas at Pine Bluff

Thank you for your interest in having Chancellor Anthony Graham, Ph.D., attend or speak at your upcoming event.

To help us effectively accommodate your request, please complete the online request form as thoroughly and accurately as possible. Be sure to include detailed information about your event to assist our team in the review process.

Please note: Submission of the online form is required before the Chancellor’s Office reviews the request and considers placing a hold on the Chancellor’s calendar. This form must be submitted at least two weeks in advance of the event date. If your event falls within the two-week window, please contact the Chancellor’s Office at (870) 575-8470.

We appreciate your understanding and look forward to reviewing your request.

* Denotes a required answer

REQUESTER INFORMATION

First and Last Name(Required)

Title(Required)

Organization(Required)

Email(Required)

Phone(Required)

EVENT INFORMATION

Event Name(Required)

Event Date(Required)

Event Location(Required)

Event Start Time *(Required)

Event End Time *(Required)

Hosting, Sponsoring, or Partnering Organization(s) (if different from above)

Event Type (select one) *(Required)

Event Attire (e.g., business casual, formal, regalia, etc.)

Event Purpose(Required)

Expected Audience(Required)

Chancellor’s role during the event(Required)

Is the Chancellor requested to attend for the duration of the event?(Required)

If you are requesting remarks, please provide 4-6 key bullet points or suggested talking points.(Required)

Are there any other speakers at the event? If so, please list their names and roles.

Please provide a draft agenda or program.

Max. file size: 100 MB.

Media or photographer/videographer will be present at this event.

Please provide any additional information about your event that we should be aware of.

File

Max. file size: 100 MB.

DAY OF EVENT CONTACT PERSON INFORMATION

First and Last Name(Required)

Cell Phone Number(Required)

Email Address(Required)

CAPTCHA

URL

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