Please fill in all fields of the meeting request form Completing this form does not commit the Department to a specific meeting. Upon completion, you will be contacted regarding your request. Name* First Last Organization Title Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Mobile Phone* Meeting Purpose* Meeting Topic Air Regulations, Permitting, Compliance Cannabis Manufacturing Regulations, Permitting, Compliance Climate Change Hemp Manufacturing Regulations, Permitting, Compliance Infrastructure Funding/Projects (e.g., Water Infrastructure Financing, Capital Outlay, etc.) Occupational Health and Safety Office of the Secretary Petroleum Storage Tanks Public Pool/Spa Regulations, Permitting, Compliance Radiation Equipment Regulations, Licensing, Compliance Restaurant or Food Manufacturing Regulations, Permitting, Compliance Septic System/Liquid Waste Regulations, Permitting, Compliance Water – Drinking Water Regulations, Permitting, Compliance Water – Groundwater Regulations, Permitting, Compliance Water – Surface Water Regulation, Permitting, Compliance Waste – Hazardous Waste Regulations, Permitting, Compliance Waste – Solid Regulations, Permitting, Compliance Other (Please Specify) Other Meeting Topic Format of Meeting In-personTeleconferenceWebExMS TeamsOther Format (Specify) If Format is not listed Select “Other Format” and fill in the field below. Other Meeting Format Meeting Participants Enter each participant on a new line: Name/Title/Representing Note: If you are a Lobbyist or government relations representative, please list all technical, legal, and other colleagues who will attend the meeting with you. Flexible on timing of meeting? Yes NO Preferred meeting date/time? MM slash DD slash YYYY Time : Hours Minutes AMPM AM/PM Second Preferred meeting date/time? MM slash DD slash YYYY Time : Hours Minutes AMPM AM/PM Third Preferred meeting date/time? MM slash DD slash YYYY Time : Hours Minutes AMPM AM/PM Meeting Duration: 15 minutes 30 minutes 45 minutes 60 minutes Is this matter urgent? NoYes Will Counsel be present?* NoYes If yes, please list name and affiliation. Counsel Name/Title/Firm Name First Last Title Firm Name This field is for validation purposes and should be left unchanged.
