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Special Appearance Request Form

A printable version of the Special Appearance Request Form can be found here.

If you would like to request the appearance of the Chairman or Board Member at your event, please fill out the form below. Please submit request at least 2-4 weeks prior to the date of the event. All request will be reviewed on a first-come, first-served basis and will be fulfilled depending on the Board Member’s prior schedule.

The form must be completed in its entirety for consideration

Special Appearance Request Form

Requestor's Name:(Required)

First Last

Phone Number:(Required)

Email(Required)

Commissioner Requested (Check all that apply - Please note all Commissioners may not be available for your event):

Oz Nesbitt, Sr., Chairman

Sherri L. Washington, Post 1

Doreen Williams, Post 2

Name of Organization:(Required)

Name

First Last

Name of Event:(Required)

Date of Event/Appearance:(Required)

Event Start Time:(Required)

:

Time Speaker is Needed (Time and Duration):(Required)

:

Exact Address of Event:(Required)

Indoor or Outdoor Event:(Required)

Indoor

Outdoor

Event Description:(Required)

Purpose for Appearance:(Required)

Suggested words or comments for speaker:(Required)

On-site Contact (Primary) Name/Cell #:(Required)

On-site Contact (Secondary) Name/Cell #:(Required)

44363

A friendly and safe environment must be maintained. The requested speaker reserves the right to walk away from any appearance deemed unsafe or harmful.

*All requests pending approval*

Address

958 Milstead Ave.
Conyers, GA 30012

Office Hours:
8:00 am - 5:00 pm
Monday through Friday

Numbers:

Telephone: (770) 278-7050

Emails:

Publicrelations@rockdalecountyga.gov