Date of submission *

Date of Meeting for which appearance sought *

Agenda Item

Non-Agenda Item

Name *

Organization (if any)

Address

Phone *

Email Address *

I am speaking for
myself
my organization
another person

I am a customer of the BLW
I am not a customer of the BLW

If you represent an organization or another person, please identify below

I have a financial interest in the matter
I do not have a financial interest in the matter

You may attach a written narrative of your presentation, any copies of documents, materials, exhibits, diagrams, etc. that you wish for the Board to consider or review.