DATE:  _______________

I/We request the City Clerk to place on the Council agenda for the _______ day of _________________, 200___ the following matter/matters for discussion and/or appropriate action:

(Below is a summary of the presentation and the action requested)

_____________________________________________________

_____________________________________________________

_____________________________________________________

Name and address of individual or group requesting time:

_______________________________________

_______________________________________

_______________________________________

Phone: __________________________

DATE RECEIVED AT CITY HALL:  _____________________

                                  RECEIVED BY:   _____________________