Privileges of the Floor Request Form

2. Speaker's Name:*

   (Any person wishing to speak on behalf of a group shall so indicate and shall identify the name and address of the group or organization.)

4. Address:*

6. Phone #:*

7. Email:

9. Please mark the City Commission District of your Residence:*
   1. District 1-Commissioner Kevin Dorsey
   2. District 2-Commissioner Janasky Fleming
   3. District 3-Commissioner Albert Kirkland
   4. District 4-Commissioner John Ferguson
   5. District 5-Commissioner Beth Kenward
   6. District 6-Commissioner David Crutchfield
11. Topic to be addressed:*

Leave This Blank:


12. 1. Receive email copy
13. Email address

    This field is not part of the form submission.

14. Submit Submit and Print

* indicates a required field