Form Receipt Confirmation

Please provide information about the City official or employee who submitted a form to your agency, board, or commission, as well as the date that you received the form.

Form: *

Filer's Name: *

^This is the name of the City official or employee who submitted the form to you.

Filer's Agency or Board: *

Receipt Date: *

Month

Day

Year

Please sign below, confirming receipt of the above mentioned form.

I HEREBY ACKNOWLEDGE THAT I RECEIVED THE ABOVE MENTIONED FORM AND THAT MY TYPED NAME SHALL SERVE AS AN ELECTRONIC SIGNATURE: *

Email Address: *

Date: *

Month

Day

Year

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Form Receipt Confirmation