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Request to Speak at City Council Work Session on Non-Agenda Items (Citizen Matters)

2. Today's Date
   Today's Date
3. Session Date*
   -- Select One --March 18, 2021April 8, 2021April 22, 2021May 6, 2021May 20, 2021June 10, 2021July 22, 2021August 5, 2021August 19, 2021September 9, 2021September 23, 2021October 7, 2021October 21, 2021November 4, 2021November 18, 2021December 9, 2021December 23, 2021
4. First Name*
6. Last Name*
7. Address
9. City
10. State
11. Zip Code
13. Email
14. Phone Number
15. Fax Number
17. Organization Represented
19. Topic*
    Statement of action you wish the council to take.
21. Presentation

    1. Yes

    1. No

    Will you be presenting a PowerPoint presentation, or a video?
22. Communication

    1. Yes

    1. No

    Have you communicated with the Department Director associated with this matter?
24. Please Note: You are permitted 3 minutes to speak and make your presentation.
    
    This form must be submitted to the Agenda Coordinator by Monday at 5 p.m. 10 calendar days prior to the City Council Work Session meeting at which you wish to speak. Once this form is submitted, no further reminder will be given. Citizens may call the Agenda Coordinator's Office at 919-560-4222 to confirm receipt of this form.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field