Suffolk County Legislature Form Center

ADVISORY BODIES MEETING PARTICIPANT/SPEAKER CARD

2. Choose an Advisory Body*
   -- Select One --Addiction Prevention and Support Advisory PanelCampaign Finance BoardCoindre Hall Advisory BoardFair Housing Task ForceFood Policy CouncilLake Ronkonkoma Advisory BoardMarine Industry Revitalization Advisory CouncilTeen Pregnancy Advisory BoardVanderbilt Museum

3. Meeting Date:*
   Meeting Date:

5. Are you submitting this form to:*

   1. Speak (limited to 3 minutes)

   1. Participate

7. REQUEST TO PARTICIPATE/ADDRESS THE ABOVE SELECTED ADVISORY BODY
   Speakers are limited to three (3) minutes. Longer statements may be submitted in writing to the Clerk for distribution and shall become part of the permanent record if desired.

   Speakers are limited to three (3) minutes. Longer statements may be submitted in writing to the Clerk for distribution and shall become part of the permanent record if desired.

9. First Name:*

10. Last Name:*

12. E-Mail:*

14. Address:*

16. City:*

17. State:*

18. Zip Code:*

20. Phone Number:*

22. Representing:

24. Topic:*

26. Device being used to speak: *

    1. Computer or Tablet

    1. Telephone

28. If using a computer or tablet, what is your device name:

30. If using a phone, what is your phone number:

32. If you require an interpreter, please specify the language below:

34. SPECIAL ACCOMODATION REQUESTS SHOULD BE DIRECTED TO THE CLERK OF THE LEGISLATURE AT (631) 853-4074.

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