REQUEST TO SPEAK FORM
Pike County Fiscal Court – Public Comment / Agenda Request
Purpose: This form allows residents to request placement on the agenda or permission to speak during a Pike County Fiscal Court meeting.
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1. Applicant Information
Full Name: _
Mailing Address: _
City/State/ZIP:
Phone Number: _
Email Address: _
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2. Meeting Information
Requested Meeting Date:
Are you requesting:
- ☐ Agenda Placement (to present a specific item)
- ☐ Public Comment (general remarks)
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3. Topic You Wish to Address
Title / Subject of Issue:
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Summary of What You Intend to Present (2–3 sentences):
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4. Requested Action (Optional)
If you are asking the Fiscal Court to take a specific action, describe it below.
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5. Supporting Materials
Will you be submitting documents, photos, or other materials?
- ☐ Yes
- ☐ No
If yes, please describe:
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6. Acknowledgment
By signing below, I acknowledge that:
- My request is subject to approval by the Judge/Executive’s office.
- I may be contacted for clarification or scheduling.
- I agree to follo
w all meeting rules and decorum requirements.
Signature:
Date: _
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