Suffolk County Legislature Form Center

2. Choose an Advisory Body*
   -- Select One --Addiction Prevention and Support Advisory PanelCoindre Hall Advisory BoardSiting of Memorials & SymbolsTeen Pregnancy Advisory Board
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 at Frank.Tassone@suffolkcountyny.gov for distribution and shall become part of the permanent record if desired.

9. First Name:*
10. Last Name:*
12. How would you like to be addressed?
14. E-Mail:*
16. Address:*
18. City:*
19. State:*
20. Zip Code:*
22. Phone Number:*
24. Representing:
26. Topic:*
28. Device being used to speak:

    1. Computer or Tablet
    2. Telephone

    1. I will be speaking in person at the meeting
30. If using a computer or tablet, what is your device name:
32. If using a phone, what is your phone number:
34. If you require an interpreter, please specify the language below:
36. SPECIAL ACCOMODATION REQUESTS SHOULD BE DIRECTED TO THE CLERK OF THE LEGISLATURE AT (631) 853-4074.
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field