Scheduling Request Form
Please fill out the form in full. Representative Parkhurst's office will be in contact with you.
All requests will be processed in the order they are accepted and availability.
Do Not fill out multiple forms for one scheduling request.
Email address *
Type of request *
For whom are you requesting the meeting? *
e.g. Association, Individual, Company, Group, etc. Please include the full name of the individual, company or organization.
Your answer
Date(s) *
Express one date as mm/dd, a date range as mm/dd-mm/dd and a variety of dates as mm/dd, mm/dd, etc. If you are flexible on the date, please write "Flexible."
Your answer
Time *
If you are requesting a specific time, please choose "other" and write the time. If you can do both morning and afternoon, please choose "Flexible."
Location *
If other, please provide the full address of the location
Attendees *
Please include a list of all attendees in this format: Full Name (Title, Company), Full Name (Title, Company), Full Name (Title, Company), etc. If you are requesting the Representative's attendance at an event or reception, please include how many attendees you expect to be at the event and the general make-up of the group.
Your answer
Agenda *
Please include the specific topics you would like to discuss or the agenda for the event depending on your type of request.
Your answer
Point of Contact *
Full name
Your answer
*
Title and Company
Your answer
*
Email
Your answer
*
Phone number
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Illinois House Republican Staff. Report Abuse - Terms of Service - Additional Terms