Proclamation Request Form

Proclamation Request

Date of Request

Month Day Year

Date Needed

Month Day Year

Full Name of Requestor *

First Name Last Name

Mailing Address

City

State

Zip code

Phone Number

E-Mail Address *

Proclamation Delivery Method

I Will Pick Up Proclamation Please Mail Proclamation* (See box below) I am requesting a Proclamation presentation at a City Council meeting I am requesting a Proclamation presentation at an event

Name of event, date/time, and location that Proclamation is to be presented at

If the Proclamation should be mailed to someone else, please provide the Name and Address of the recipient:

Brief summary and/or background of the event, organization, or individual:

Please use this space (or attach separately) a draft with the exact wording of the Proclamation to include at least four to 6 "whereas" clauses:

"whereas" clauses

Name(s) and dates of the day, week, or month to be proclaimed - (Example: Thursday, May 22, 2014, proclaimed as John Doe Day in the City of Xenia OR the month of May 2014 proclaimed as Motorcycle Awareness Month)

Enter the message as it's shown *