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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 6 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 30, 2019, proclaimed as John Doe Day in the City of Xenia or the month of May 2019 proclaimed as Motorcycle Awareness Month
Leave This Blank:


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

    This field is not part of the form submission.

38. Submit

* indicates a required field