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2. Disclaimer
   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
4. Proclamation Title*
6. Name of Individual or Organization Requesting the Proclamation*
8. Please Answer the Following: *

   1. A Single Day (e.g. National Adoption Day)
   2. A Week (e.g. Public Health Week)
   3. A Month (e.g. Older Americans Month)

   Which date span do you wish to proclaim? A date option will appear based on your selection.
10. Date to Proclaim - Single Day*
    Date to Proclaim - Single Day
    Please select the single date you request to proclaim.
12. Date to Proclaim - Week*
    Date to Proclaim - Week Start Date

    —

    Date to Proclaim - Week End Date
    Please select the week-long period you wish to proclaim.
14. Date to Proclaim - Month*
    Date to Proclaim - Month Start Date

    —

    Date to Proclaim - Month End Date
    Please select the month-long period you wish to proclaim.
16. Date To Be Issued*
    Date To Be Issued
    Please select the day you wish the proclamation to be issued and/or dated.
18. Delivery Method*

    Please select the desired delivery of your requested proclamation.

    1. During a Public Hearing
    2. At an Off-Site Event
    3. At a Jeffco Event (Internal)
    4. None (just send me the proclamation)
20. Sample Proclamation Language*
    If attaching a file with the sample proclamation language, please type "N/A"
22. Upload
    Upload a draft copy of your proclamation
24. Requested By:
26. Name*
27. Email Address*
28. Phone Number*
30. Street Address*
32. City*
33. State*
34. Zip Code
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field