Coverage Request Information:

Organization Name

Event Name

Event Date

YYYY

Event Time

When would you like DUEMS to be present?

Hour

Minute

Second

Event Location

Expected number of attendees

Fund Code

(if paying by check, write “check”)

DUEMS requests that event sponsors provide a table and two chairs for our staff to stage from, as well as a tent if the event is outdoors and inclement weather is possible.

I understand this and will provide the table and chairs, and tent as needed:

Contact Name

First Name

Last Name

Contact Email