CITIZEN
REQUEST TO BE PLACED
ON THE COUNTY COMMISSION AGENDA
UNDER SCHEDULED PRESENTATIONS

NOTE: THIS REQUEST FORM MUST BE SUBMITTED TO THE COUNTY ADMINISTRATORS OFFICE BY 5:00 WEDNESDAY ON THE THIRTEENTH DAY PRIOR TO THE NEXT COMMISSION MEETING DATE. (This is necessary in order to give staff time to do appropriate research on the issue prior to initiating preparation of the agenda on the following Tuesday).

INDIVIDUAL MAKING PRESENTATION:

Name:
Address:
City:
State:
Zip:
Phone (Home):
Phone (Work):
Email:

REQUESTED DATE TO BE PLACED ON AGENDA
Please Enter Board Meeting Date

SUBJECT MATTER (Please be specific):

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REQUESTED ACTION, IF ANY:

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November 21, 2017
TYPED SIGNATUREDATE