Request for Placement of Item on City Council Agenda
Preferred Date to be Agendized: ________________ Second Choice of Date: ________________________
Notification Information: Date of Request: ____________________
Name: ____________________________ Email: ____________________________
Address: __________________________ Mailing Address (if different): __________________________
City: _____________________________ City: __________________________ Zip Code: ___________
Home Telephone: __________________ Cell Telephone: _________________ FAX #: _____________
Item to be Agendized: (Give a brief summary of the item you are requesting to be placed on the Agenda.
The item will be considered by staff and/or members of the City Council and when a decision has been
reached, the requestor shall be notified). Type or print legibly. The item, if agendized, will be placed on
the agenda using your specific wording: ______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
At all Regular City Council Meetings members of the public are provided the opportunity to address the City
Council on items not on the Agenda or those items on the Consent Agenda. The public is also given the
opportunity to comment on any item on the Agenda during Council discussion of that item, with the exception
of any item that was continued from a legally noticed Public Hearing that has been closed. Council may ask
questions but may take no formal action on items addressed during the Public Comment period.
Please complete the following information for use if the item is Agendized:
Will it be a Verbal presentation only? ____yes ____no
Written material accompanying item: ____yes ____no (Material must be submitted by agenda deadline
for distribution in order to be heard). Number of handouts: ______ Number of pages: _________
Will there be Handouts or a PowerPoint Presentation?:__________________________________________
Will others be speaking on this item? ________________________________________________________
Estimated number of speakers: ______ Names of speakers: ______________________________________
Estimated amount of time needed for discussion: ______________________________________________
NOTE: REQUESTS ARE TO BE GIVEN TO THE DEPUTY CITY CLERK NO LATER THAN 12:00 NOON, TWELVE
(12) WORKING DAYS PRIOR TO THE REGULAR CITY COUNCIL MEETING AT WHICH IT IS TO BE
CONSIDERED AND IS SUBJECT TO THE DISCRETION OF THE COUNCILMEMBERS AND STAFF.
I have read and understand the information provided herein: ________________________________
SIGNATURE
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____Item Approved to be Agendized for the ________________________ Regular City Council Meeting.
____Item has been forwarded to _______________________________ for response on behalf of the City.
____Item is not within the Jurisdiction of the City Council and has not been Agendized.
____Item has not been Agendized at this time. Determination by: _______________________
MT. SHASTA CITY HALL | 305 NORTH MT. SHASTA BLVD. | MT. SHASTA, CA 96067 | (530) 926-7510
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