Complete and submit this form to request Congressman Gallagher's appearance at a meeting, speaking function, or a non-speaking function. Due to the Member's schedule, not all requests will be filled. * marks required fields of data. Activity Details Type of Request: * - Select -Appearance (non-speaking)Meeting RequestSpeaking Request Location of Event: * - Select -In DistrictIn Washington, DC or elsewhere Date of Engagement: * Year Year202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Number of Attendees: * Topic of Engagement: * Details: * Your Information Prefix: * - Select -Ms.Miss.Mrs.Mr.Mr. and Mrs.Rev.Dr.The HonorableRabbi First Name: * MI: Last Name: * Suffix: - None -2nd3rd4thIIIIIIVJr.Sr.M.D.PH.D.and Family Your Organization Organization: * Your Title: * Organization’s Website: * Your Contact Information Street Address: * Street Address Continued: City: * State: * Zip Code: * +4 Extension: Email: * Telephone Phone Number * Phone Type: Standard voice telephoneVideophone [VP]Text-telephone device [TTD] What are these options? Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option "Voice" is a standard audible telephone.