2. City of Parkland Dedication Policy Information Form
   (Please complete the form as fully as possible)
4. Name of individual completing the form*
6. E-mail of individual completing the form *
7. Phone number of the individual completing the form*
9. Relationship to the individual whose name is being proposed *
11. Age of the person being proposed if they are not deceased.*
13. What City facility / site is being proposed to be named?*
15. Provide any information you believe speaks to the quality and character of the individual whose name is being proposed.
17. Describe the quality of the contribution this individual has made to the community—with a focus on service and public contribution, not political affiliation.*
19. Provide information that highlights how the name being proposed would contribute to the historic integrity of the facility / site.
21. Are there any other installations in the City of Parkland that already carry the proposed name.*

    1. Yes
    2. No
23. To enable the Committee to make a fully-informed decision, any information in this individual’s background that might reflect unfavorably on them and anything to which their name might be affiliated.
25. Any other information that might be pertinent.
27. The City of Parkland is governed by the Public Records Act as set forth in Chapter 119, Florida Statutes. Under Florida law, information, photographs, videos, e-mail addresses etc… are public records and subject to disclosure.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field