Requested By

Is this request from a State Agency? Is this request from a State Agency? NoIs this request from a State Agency? Yes	Title **
First (Legal) Name **	Last Name **
Preferred Name *	Job Title *
Organization Name **	Phone **
Email ***	Title of the Proclamation (e.g. Virginia Volunteer Week ) **
Start Date (mm/dd/yyyy) **	End Date (mm/dd/yyyy) **
Date Needed **	Indicate if you will pick up the proclamation or if you would like it mailed * Mail Pick up
Address Information : Street Address **
City **
State **
Zip Code **
In the space provided below please provide a summary/background of the individual, group or organization making the request **
Please use the following space to cite the sources for any statistics and/or other information used in your proposed verbiage **
In the space provided below please provide proposed verbiage including 5-6 Whereas Clauses **

Deliver To

Deliver to same as requested by
Name **
Street Address **
City **
State **
Zip Code **

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