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2. First Name*
3. Last Name*
5. Email Address*
   If you do not have one, please provide the email address of a contact in your organization to whom we can provide details and updates for this Tele-engage request.
7. Home Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
    (xxx) xxx-xxxx
14. Which type of phone number?*

    1. Home
    2. Mobile

    1. Work
16. What is the name of your organization?*
18. Which of the following best describes your organization?*

    1. Block Club

    1. Local Community Group

    1. Non-Government Organization (NGO)
20. What is the name of your event?*
22. What is the primary purpose of your event?*

    1. Advocacy / Issue Forum (i.e. community concerns)
    2. Instructional / Educational (i.e. panel, lesson)
    3. Social / Ceremonial
24. Which of the following issues do you plan to discuss at the meeting?*

    1. Beautification
    2. Blight
    3. Crime / Policing
    4. Food Insecurity

    1. Lack of Resources (gloves, masks, etc.)
    2. Potholes
    3. Poverty

    1. Vacant Lots
    2. Violations
    3. Other
26. Other
    Please briefly write what you plan to discuss at the meeting with the City Hall representative.
28. Meeting Date*
    Meeting Date
    Please select a preferred meeting date.
29. Meeting Time*
    Meeting Time
    60 minute time slot between 4 - 8 PM only
31. How many attendees do you expect?

    1. 1 - 10

    1. 11 - 20

    1. 21 - 50

    1. 50+
33. Will a majority of attendees be in the youth demographic? (ages 18-29)*

    1. Yes

    1. No

    1. Unsure
35. Will a majority of attendees be of older age? (ages 65+)*

    1. Yes

    1. No

    1. Unsure
37. From which of the following departments would you like a representative to attend?*

    1. Buffalo Employment and Training Center (BETC)
    2. Department of Community Services
    3. Division of Citizen Services
    4. Permit & Inspection Services

    1. Police
    2. Public Works
    3. Other (Type in Below)
39. If "Other" above, please type in the Department.
41. Is there a specific city representative you would like to request?
    Please type in his / her name.
43. Will you need flyer or advertising support to publicize this meeting?*

    1. Yes

    1. No
45. Do you have your own video conferencing link to use for the meeting?*

    1. Yes

    1. No
47. If "Yes" above, please paste the video conferencing link here.
49. Will you need assistance in video conferencing set-up?*

    1. Yes

    1. No

    Note: We require you to participate in a video conferencing training if you do not have your own conference link
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field