E-mail Address:
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Requesting Person:
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SHHS Department or Requesting Organization:
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Phone Number:
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Todays Date
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Please Check Type of Event: ( Internal= SHHS Associates, External = Community)
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Internal ONLY
External ONLY
BOTH Internal and External
Physician ONLY
Title of Event:
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Date of Event:
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Alternate Event Dates:
Time of Event (i.e. 6:00 am - 4:00 pm):
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Set-up Time Required (i.e. 30”):
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Number of People Expected:
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Specific Room Requested:
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None - REQUESTING ANY AVAILABLE ROOM
Dudlely Greenhut Auditorium
Lecture Hall
MOB Conference Room
W/C Conference Room A/B
W/C Conference Room C/D
Medstaff A
Medstaff B
Medstaff A AND B
Lecture A
Lecture B
Room Setup Requested:
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Theater Style
Classroom Style
Conference Style
Banquet Style
Specific Setup - My Diagram is Attached
Attach Your Specific Setup Room Diagram (this may be in the form of a Word Document, Adobe Document, etc.):
Audio/Visual Needs:
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None
Laptop Computer
Computer Projector
Overhead Projector
Slide Projector
Audio CD/Tape Player
TV/DVD
TV/VCR
Microphone
Other
Audio/Visual Needs - Other (Please identify what other audio/visual needs you have that were not indicated above).
Description of Course including Purpose and/or Objectivies of the Event:
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Is there a Fee Charged for the Event?
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Yes
No
If Yes, What is the Amount?
For Office Use Only
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Required