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2. Date of Application:
   Date of Application:

4. The City of Key West

   P.O. Box 1409

   Key West, FL  33041-1409

5. 

6. Ryan Stachurski

   Multimodal Transportation Coordinator

   Phone: (305) 809-3867

8. The City of Key West makes available tools and resources necessary for safe bicycling and walking. Local schools, non-profit organizations, government agencies, and community groups are encouraged to partner with the City of Key West to provide safety information and tangible safety items (e.g. lights, helmets, vests, etc.) to those in your community.

   To sign-up in the Community Safety Ambassador Program, complete this form and click submit at the bottom of the form. Please remember to include your email to receive a copy of your submittal.

   
   

10. Organization Type:

    1. Community Groups
    2. Government
    3. Non-Profit (Charity / Religious)
    4. School
12. Organization Name:
14. Contact Name:
16. Contact Title:
18. Contact E-mail:
20. Contact Phone:
22. Electronic Signature Agreement

    1. I agree as a Community Safety Ambassador that Distribute safety materials for the intended purpose, free of charge to individuals without regard to race, sex, disability, age, veteran status, national origin, religion, marital status, or political affiliation.

    By checking the "I agree" box, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

24. Electronic Signature
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print