EmailMe Form - 2013 Potentate and Divan Visitation Request

2013 Potentate and Divan Visitation Request

Ill. Sir Jim Wilson is planning his calendar for 2013. He will be visiting all clubs, units and other groups during 2013. If you would like to request a special visit or schedule an "Official Visit" with the Divan included, please utilize this request form. Review the online calendar for any conflicts. All the potentate's meetings and visitations are in RED.

All * fields are required. Data will be submitted to both Jim Wilson and his Chief Aide. Once confirmed, you will receive an email confirmation and the date will be added to the calendar.

Club, Unit or Organization Name *
Shrine Club, Shrine Unit or Other Organization
Contact Name *
First Last
Contact's Email *

Confirm Email
Phone (include Area Code) *
### - ### - ####
Event Date *
MM / DD / YYYY
Time to Arrive *
HH : MM AM/PM
What time do you want the potentate to arrive?
Time The Events Starts? *
HH : MM AM/PM
Actual start of the event.
Address of Event *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Physical address of event.
Type of Event.
Stated Meeting, Installation
of Officers,Fund Raiser, Public Information address, etc *
Dress Code Attire:
casual, suit & tie, formal. *
Is there a meal served? *
Are Ladies welcome at
this event? *
Do you want the Divan officers and other appointees included? *
Additional comments that need to be known to all attending.
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