Request for Department Officer - Electronic

DATE:         District Number: Dist 4 Dist 5 Dist 6 Dist 7 Dist 8 Dist 9 Dist 10 Dist 11 Dist 12 Dist 13 Dist 14 Dist 15           Post Number:    
              (mm/dd/yyyy)

Date of Function:   Time of Function:
                                      (mm/dd/yyyy)                                           ( hh:mm /  a.m/p.m.)

Name of Function (District Meeting, PC/PP Banquet, etc.)

Location of Function:
Address:
City:       
State:     
Zip:         

                             ( Department Officer Choice) Please choose up to 3 Persons
First Choice:
Second Choice:
Third Choice:

Contact Person:
Address: 
City, State, Zip:
Phone Number:    Email Address:
                                       (555-555-1234)

Requested as:
Dress:

Department Headquarters will contact the person who submitted this request after the assignment has been made.  They will need information for the person selected on how to get to your requested site and any overnight area Hotel/Motels (address/phone).

 Note:  When your Confirmation Form appears when you submit this report...Print a copy of the report for your records.