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For Office Use Only: Application Complete Fee Received Petition Complete <br />Comments: <br /> APPROVE DENY <br />1.Applicant Information <br />Applicant’s Name:Date: <br />Applicant’s Address: <br />Email Address: Telephone/Cell: <br />2.Honorary Sign Request: <br />Name of Requested Sign Honoree: <br />Is this individual deceased? ____Yes _____No (If no, individual is not eligible for honorary sign.) <br />Proposed Location: Intersection of _________________________ & __________________________ <br />Location #2 (optional): Intersection of _______________________ & __________________________ <br />Location #3 (optional): Intersection of _______________________ & __________________________ <br />Location #4 (optional): Intersection of _______________________ & __________________________ <br />(Example: Intersection of North and South Street) <br />Did the individual live in South Bend? ____Yes _____No (If no, individual may not be eligible for honorary sign.) <br />Significance of Location to Honoree's Life: ________________________________________________________ <br />___________________________________________________________________________________________ <br />___________________________________________________________________________________________ <br />___________________________________________________________________________________________ <br />3.Required Submittals: <br />Please submit the following items along with your request: <br />A statement of not less than 500 words describing the significance of the person being honored. The <br />statement should include detailed information about the proposed Honoree summarizing the Honoree's <br />accomplishments, connection and contribution to South Bend, Indiana, and reasons as to why the person <br />should be publicly recognized. <br />A petition of support for the proposed Honorary Sign or Honorary Feature. The petition should be signed <br />by not less than two hundred (200) residents of South Bend and must include the name, address, age, <br />signature, and date of signing. [Note: All information on the petition must be legible in order to be <br />considered.] <br />Upon submission of this Application and required submittals, please allow eight (8) weeks for staff to review, <br />and present to the City's Board of Public Works for final action. A letter will be sent to the Applicant indicating <br />the Board's decision. In the event that the Application is denied, the Fee will be refunded to the Applicant. <br />4.SIGNATURE OF APPLICANT <br />My application consists of the following items: (Please check) <br />a. Completed Application Form plus one (1) copy <br />b. $150.00 Application Fee (Make checks payable to: City of South Bend) <br />c. Typed statement describing the significance of the person being honored as described above. <br />d. Petition of support <br />Signature Date <br />Printed Name