2. Event Name:*
3. Event Website:
   If applicable
5. Physical Address of the Event*
7. City*
8. State
9. Zip Code
11. Day of the Event:*
    Day of the Event:
12. Event Time Frame*
    Event Time Frame Start Time

    —

    Event Time Frame End Time
    Please list desired arrival and anticipated departure times (include set-up, etc.)
13. Event Date is:

    1. Flexible
    2. To Be Determined

    Please check, if applicable
15. Event Organizer*
    (Business or organization name)
17. Organizer Address
18. City*
20. State
21. Zip Code
22. Phone Number
24. Primary Contact Name for Event*
25. Email Address*
26. Contact Cell Phone*
28. Please briefly describe your event:*
30. Type of Event*
    -- Select One --Career Fair (for High School and Older)School VisitFundraiserDrug Prevention and AwarenessGang Prevention and AwarenessNeighborhood MeetingOther

    Select the most applicable category for your event.
31. Other Category
    If you selected "Other" under "Type of Event" please describe the kind of event here.
32. Approx. Number of Attendees
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field