If you would like to make a request for the First Lady to attend or speak at an event, please fill out the following request form and be sure to fill in each of blanks on this form. After you have filled in all of the information, click on the ‘Submit’ button and you will receive an e-mail confirming that your request has been received by the First Lady’s office. Please submit your scheduling request for an event that is at least two weeks from today’s date. Thank you.

Contact Information
           Prefix First Name Last Name  
Home Phone Work Phone Email  

Speech/Event Information
            Name of Event 
Speech Topic
Request Type
Date of Event 
Day of Week
Speaking Time  
Speech Length
Name of Person Introducing the First Lady  
Other Speakers 

           Event Begin Time Event End Time Inside or Outside
Location Event  
Name of Facility  
Facility Address  
Directions to Facility From Nearest Airport’  
Name of Group of Sponsor Organization  
Contact Person 1  
Contact Person 2
Emergency Cell Phone Number  

Estimated Attendance  
Media Attending  

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State Agencies

Governor Haley Barbour
P.O. Box 139 Jackson, MS 39201
Phone: 601.359.3150 Fax: 601.359.