Proclamation Request Form

Proclamation Request

Date of Request

MonthDayYear

Date Needed

MonthDayYear

Full Name of Requestor*

First NameLast Name

Mailing Address

City

State

Zip code

Phone Number

E-Mail Address*

Proclamation Delivery Method

I Will Pick Up ProclamationPlease Mail Proclamation* (See box below)I am requesting a Proclamation presentation at a City Council meetingI 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)

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