Michigan Department of State
Mobile Office Visit Request Form

Question Title

* 1. Please provide the following information:

Host organization:

Web address:

Contact person/title:

Phone:

Email:

Street address:

City, state, zip code:

Number of people your organization services:

Question Title

* 2. Please provide the type of community your organization serves:

Returning citizens

Homeless/housing insecure

Senior citizens

Military and veterans

Limited English proficiency

Foster youth

People with disabilities

Other (please specify)

Question Title

* 3. Will the Mobile Office visit be part of an event?

Yes

Question Title

* 4. Please select your region:

Southeast Michigan

Mid Michigan

West Michigan

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* 5. Mobile Office visit details:

Brief description:

Preferred date:

Preferred time:

List of alternate dates:

Location name:

Street address:

City, state, zip code:

Number of attendees expected:

Media invited (yes or no):

Michigan Department of StateMobile Office Visit Request Form

Question Title

* 1. Please provide the following information:

Question Title

* 2. Please provide the type of community your organization serves:

Question Title

* 3. Will the Mobile Office visit be part of an event?

Question Title

* 4. Please select your region:

Question Title

* 5. Mobile Office visit details:

Question Title

* 6. Additional information/comments:

Michigan Department of State
Mobile Office Visit Request Form