Loma Rica /

   Browns Valley

        Fire Department

LOMA RICA STATION #61

11485 LOMA RICA ROAD

BROWNS VALLEY STATION #62

9471 BROWNS VALLEY SCHOOL RD.

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REQUEST TO HOLD PLACE ON AGENDA

 

Please type or print clearly.

 

This form must accompany material to be presented to the Board of Directors for their meeting.  An incomplete form may result in a

delay in your item being presented to the Board.

 

 

SUBJECT:______________________________________________________________________________

 

 ______________________________________________________________________________________

 

 ______________________________________________________________________________________

 

 

 ACTION  REQUESTED:__________________________________________________________________

 

 ______________________________________________________________________________________

 

 ______________________________________________________________________________________

 

 ______________________________________________________________________________________

 

 

 MEETING DATE REQUESTED *___________________________________________________________

 

 

 NAME (Print or Typed)____________________________________________________________________

 

 ADDRESS _____________________________________________________________________________

 

 TELEPHONE NUMBER __________________________________________________________________

 

 SIGNATURE ___________________________________________________________________________

 

 

  APPLICANT IS ADVISED TO INCLUDE ANY PERTINENT DOCUMENTS / PAPERS FOR BOARD

  CONSIDERATION.  FAILURE TO DO SO COULD DELAY BOARD ACTION.

 

 

 

*  Regular District meetings are held the third Monday of each month.  When complete, this form and any supporting documentation should be forwarded to the District at 11485 Loma Rica Road, Marysville, CA 95901.  Please be advised that it may take up to 10 days

from the date of receipt of this completed form until placement on the agenda.