NAME OF PROPOSED NEIGHBORHOOD COUNCIL:

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On behalf of the Proposed Neighborhood Council named herein, the attached Neighborhood Council Certification Application is submitted to the Los Angeles City Department Of Neighborhood Empowerment, for consideration by the Board of Neighborhood Commissioners of the City. The persons listed below agree to serve as contact liaisons with the City during the neighborhood council certification process on behalf of the proposed neighborhood council. Important: This form must be signed by each person listed on the form.

As stated in Article 3, Section 2 (f) of the adopted Plan for a Citywide System of Neighborhood Councils:

"Every application shall include contact information for no less than three and no more than five people who shall act as official contacts between the applicants and DONE until the proposed Neighborhood Council is certified."

CONTACT LIAISON PERSONS:

Name (printed) ________________________________________________

Mailing Address ________________________________________________

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Telephone(s) ________________________________________________

Email address ________________________________________________

SIGNATURE ________________________________________________

Name ________________________________________________

Mailing Address ________________________________________________

________________________________________________

Telephone(s) ________________________________________________

Email address ________________________________________________

SIGNATURE ________________________________________________

Name ________________________________________________

Mailing Address ________________________________________________

________________________________________________

Telephone(s) ________________________________________________

Email address ________________________________________________

SIGNATURE ________________________________________________

Name ________________________________________________

Mailing Address ________________________________________________

________________________________________________

Telephone(s) ________________________________________________

Email address ________________________________________________

SIGNATURE ________________________________________________

Name ________________________________________________

Mailing Address ________________________________________________

________________________________________________

Telephone(s) ________________________________________________

Email address ________________________________________________

SIGNATURE ________________________________________________