Request for CPCU Society Representative

Request for CPCU Society Representative

For Conferment Ceremonies, Officer Installations, and I-Days
The purpose of this form is to gather information about your chapter's upcoming event so we can assist in securing a CPCU Society representative to attend. Please provide details about your upcoming event, and allow up to 10 business days for a Society staff member to connect with you.

Please note: Our Society representatives are available to discuss Society initiatives, updates, and the significant value of the designation and Society membership for local conferments and/or chapter officer installations. We regret to inform you that we cannot accommodate requests for RMI or specific topic-based speaking opportunities. If your chapter is seeking an RMI or a specific topic speaker, we recommend posting a request on our INteract community to find a suitable speaker.

Thank you for your understanding, and we look forward to collaborating with you for a successful event.
Chapter Contact Information
Chapter Name*
Chapter Contact's Name*

First NameLast Name
Chapter Contact's Email*
example@example.com
Chapter Contact's Phone Number
Please enter a valid phone number.
Chapter Event Information
Event Date*

MonthDayYear
Date
Attendance for this event is*

in-person onlyvirtual onlyhybrid
Event Time*

Hour Minutes

AM/PM Option
How many people do you expect to have in attendance?*
This event is a/an (select all that apply)*

Chapter officer installationLocal confermentI-DayOther
Have you booked a venue for this event?*
Event Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of venue
Event/Venue Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you plan to partner with other CPCU Society Chapters or organizations to plan this event?*

YesNoUnsure / Maybe
Name of partner chapter or organization
Speaker / CPCU Society Representative Information
Expectations for your speaker / CPCU Society representative are (select all that apply):*

Confer new designeesInstall officersSpeak on behalf of the Society about Society updates and initiatives, value of CPCU Society and/or designation, volunteering with the SocietyOther
Would you like to request a specific speaker / CPCU Society representative?*

YesNo
Name of specific speaker / CPCU Society representative
Have you contacted this CPCU Society representative?

Yes/AcceptedYes/Unavailable or DeclinedNot Contacted
What are the expectations of the CPCU Society representative?
Please be as specific as possible.
Any additional comments/questions....
Would you like to request a specific CPCU Society representative?
Should be Empty:

Request for CPCU Society Representative

Chapter Contact Information

Chapter Event Information

Speaker / CPCU Society Representative Information