Full Name and Title:*

Co-presenter (if applicable):

Name of Organization (if applicable):

Phone Number (123-456-7900):*

Alternate Phone Number (123-456-7900):

E-mail Address:*


Have you been dealing with city staff regarding your concern? If yes, please provide name and department of staff member:

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What outcome do you hope to achieve?*

Personal information is collected for the purpose of responding to your request. The City of Surrey is collecting this information under s.26(c) of the Freedom of Information and Protection of Privacy Act. For questions regarding the collection of personal information please contact the Manager of Marketing and Communications, 13450 104 Avenue, Surrey, BC V3T 1V8  |  604.591.4011