Acknowledgment <br />I (we), the undersigned, hereby acknowledge that I (we) have read the above appeal form, understand the requirements for filing an <br />appeal of a hearings official or historic review board decision, and state that the information supplied is as complete and detailed as <br />is currently possible, to the best of my (our) knowledge. <br />APPELLANT: <br />Name (print): Phone: <br />Company/Organization: <br />Address: <br />City/State/Zip: <br />Signature: <br />APPELLANT'S REPRESENTATIVE: <br />Name (print): <br />Company/Organization Al. t-Ay-,( <br />Address: 3S ttr (-FV~ <br />City/State/Zip: Gvy~ t/~ 0171 E-mail (if applicable): CW (/Wc•c,'-,? Wj JU C .CCIA Phone: ~5qI &~,-N /41C, Fax: <br />Signature: <br />IF this appeal is being filed by the affected recognized neighborhood association, complete the following: <br />Name of Association: <br />www.eugene-or.gov/planning <br />Planning & Development <br />Planning Division <br />99 W. 1011 Avenue, Eugene, OR 97401 <br />P 541.682.5377 ' F 541.685.5572 <br />Updated: October, 2012 <br />Page 2 of 2 <br />