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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: _______________________________







To complete the Application for Certification, please submit the following:


___1.   Letter of request for certification from the chief elected official, including assurances that CLG requirements will be met.


___2.   A copy of the historic preservation ordinance as adopted by the governing body.


___3.   A clearly defined map indicating the location of any historic resources already identified, including the boundaries of any district or districts, and a list of all properties.


___4.   A sample notice of public meetings of the commission (if available).


___5.   A sample copy of an agenda and minutes of a commission meeting (if available).


___6.   A sample notice to an applicant of a decision of the commission.


___7.   A list of the members of the historic preservation commission, their terms of office, a resume for each. (Use resume form for this purpose.) If professionals have not been appointed, information must be included to describe efforts to obtain them.


___8.   A copy of the rules of procedure of the historic commission.