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APPLICATION FOR REZONING DATE: RECEIVED BY: LOCATION: PLAT: TAX MAP: PARCELS: I hereby request that the property described in this application be rezoned from zoning classification to zoning classification. I hereby request a SPECIAL EXCEPTION for the purpose of OWNER: OWNER’S DESIGNATED REPRESENTATIVE: FEE PAID: CHECK ADDRESS: CASH PHONE: I certify that I am the legal owner of the property for which this application is being made and that I have identified all individuals and business entities having an ownership interest in the real property in question on the space below. OWNER’S SIGNATURE I have made, within two years, campaign contributions aggregating $250.00 or more or made gifts having an aggregate of $250.00 or more to a local government official who will consider this application. The name of that official is and the amount of the contribution was $ . The date of the contribution(s) was . APPLICANT’S ATTORNEY’S SIGNATURE OWNER’S OR APPLICANT’S SIGNATURE