Date

Agency / Neighborhood Organization Name

Contact Person

Title (optional)

Address

City

State

ZIP

Daytime Phone

Fax (optional)

Email

Boundaries of target neighborhood (by street names, railroad tracks, etc.):

For this neighborhood, I would like to request the following information:

Plans to ensure resident participation and decision making in this project:

By submitting this form, my agency/neighborhood group agrees to:

1. Include resident participation and decision making as a major project component.
2. Meet with NRC staff members to discuss details of the information study.
3. Use the provided information to identify goals and develop an action plan.
4. Complete an Information Services Evaluation Form.
5. Keep the Neighborhoods Resource Center informed of project progress.

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