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2. Name of Organization
4. Applicant's First Name
5. Applicant's Last Name
7. Applicant's Address
9. City
10. State
11. Zip Code
13. Members Name
14. Phone Number
16. Specify

    Please specify the type of activity for which this application is made (i.e., construction permit on member's home, Summer Adventures Program for member's child, etc.).

20. Date
    Date
21. Electronic Signature Agreement

    I hereby certify that the activity for which this fee exemption is requested is for the personal and non-profit use of the member or his/her immediate family.

    
    

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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field