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State Officer Request Form

Chapter Information

Chapter Requesting:

Chapter Address:

City:

State:

Zip:

Phone Number:

Number of Members:

Visit Information

Date Requested: Please enter date as: January 1, 2015

Time Event Starts: Please enter time as: 11:30 AM

Time Event Expected to End: Please enter time as: 1:00 PM

First or Only Officer Requested

Requesting Officers

Please choose which state officer you would like to have attend your event. Every effort is made to provide the officer you request, but sometimes it is not possible so please indicate your second choice in the alternate option.

Officer Requested

Select an Alternate:

Second Officer Requested

Officer Requested:

Select an Alternate

Event Details

Purpose of Visit:

Length of Presentation: If you are asking the officer to speak or fasciliate for a specific period of time, please specify that here.

Specific Assignment for Officer: What specifically would you like the officer(s) to do? Give a speech, lead a workshop, etc...

Chapter Officer Information

Chapter Officers

This information can help the officer(s) have some members in your chapter to contact to ask questions or collect information about the event or chapter.

President's Name:

President's Phone:

Vice President's Name:

Vice President's Phone:

Secretary's Name:

Secretary's Phone:

School Administration

Superintendant's Name:

Superintendant's Phone:

Principal's Name:

Principle's Phone:

Past Major Chapter Accomplishments

Directions to Meeting Place or School

Information about FFA Advisor or other Contact

Name

Cell phone

Address

City

State

Zip