Revised 10-OS-05
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PUBLIC PARTICIPATION FORM "
FOR
KERB COUNTY COMMISSIONERS' COURT
Instructions: Fill out all appropriate blanks. Please print or write legibly. Present to the County
Clerk prior to the time that the Agenda Item (or Items) you wish to address are discussed. If
you are handing out any material or documents to the Court, please make sure you have
one eztra for the Clerk to ensure that one is put into the record.
Name: i., ~	~i~	' h o tr ,~)	

Address: t ~. ~-i ~i	
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cr~1 ~` 5uJ ~ ~ .	I r
~`i'"~'•`'v~~SC
Telephone: ~ `7 ~ ~- ~ a
Place of Employment: ~
Employment Telephone: ~-~ F5 - ~ L ~ ~ °1 ~ ~- ~ ©-~)
Do you represent any particulaz group or organization? Yes ~ No
If you represent a group or organization, please state the name, address and telephone number of
such group or organization.
Which agenda Item (or Items) do you wish to address? t- C ~ ~ lM~l i~(`~ ~ ~~ Cv y ~?
In general, are you for or against such Agenda Item (or Items)? For ~ Against
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Signature
NOTE: This Public Participation Form must be presented to the County Clerk prior to the
time the agenda item(s) are discussed.
Once you reach the podium, please state your name and who/what you
represent clearly for the court reporter to accurately record who you are.