Contact Person (Name and Title) Organization Organization Website Contact Phone Contact Email Proposed Date/Time (if already scheduled) Proposed Date/Time (if already scheduled): Date Proposed Date/Time (if already scheduled): Time Length Of Meeting (Time Requested) Length Of Meeting (Time Requested) - Select -15 Minutes30 Minutes60 MinutesOther… Enter other… Number of Attendees Additional Attendee Names, Titles & Affiliations Purpose of Meeting OR Matter To Be Discussed If Meeting Is About Current Policy or Referral - Please Provide Agenda Date/Item No. Please select meeting type: In-person at County Office Building In-person off-site – please provide details Video Call Phone Call If you select meeting type In-person off-site on above, please provide details Additional Comments Leave this field blank
