Proclamation Electronic Submittal

2. Date of Request*
   Date of Request

3. Date Needed
   Date Needed

   at least 30 days from date of request

5. First Name*

6. Last Name*

8. Address1*

10. Address2

12. City*

13. State*

14. Zip*

16. Telephone Number*

17. Email Address*

19. If approved, how should the City of Xenia get the Proclamation to you?*
    -- Select One --I will pick up the proclamation in the City Clerk's Office. Please mail the proclamation to the address provided above.Please mail the proclamation to someone else.I am requesting a proclamation presentation at my event.I am requesting a proclamation presentation at a city council meeting.

21. If the proclamation should be mailed to someone else, please provide the name and address of the recipient:

23. If you are requesting a proclamation presentation at your event, please provide the name of the event, date/time and location:

25. If you are requesting a proclamation presentation at a City Council meeting, please provide at least two upcoming Council meeting dates that would accommodate you.

    The Council meeting dates you select should be after the 30-day period. The Council meets on the 2nd and 4th Thursday of each month at 7 p.m.

    The Council meeting dates you select should be after the 30-day period. The Council meets on the 2nd and 4th Thursday of each month at 7 p.m.

27. 1st Date
    1st Date

28. 2nd Date
    2nd Date

30. Please provide a brief summary and/or background of the event, organization, or individual:*

32. Please use this space to provide the exact wording in the Proclamation to include at least four "whereas" statements:

34. Name(s) and dates of the day, week, or month to be proclaimed:

    Example: Thursday, May 28, 2015, proclaimed as John Doe Day in the City of Xenia or the month of May 2015 proclaimed as Motorcycle Awareness Month

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field