APPLICATION FOR CERTIFIED LOCAL GOVERNMENT STATUS

Official Name of Government

Requesting Certification: ________________________________________

Name of Chief Elected Official: ________________________________________

Address: ________________________________________

________________________________________

Name of Contact Person: ____________________________ Phone: _______

Name of Historic Preservation

Commission: ________________________________________

Name of Historic Preservation

Commission Chairman: ________________________________________

Address (if different than

above): ________________________________________

________________________________________ Phone: __________

Time and Place of

Commission Meetings: ________________________________________