SEVENTH DISTRICT CERTIFICATE REQUEST FORM
Please read the criteria below before submitting the certificate request form.

- Certificates are provided as a courtesy and issued by Los Angeles City Councilwoman Monica Rodriguez to recognize and honor individuals for their contributions to the Seventh Council District and the City of Los Angeles.

- Certificates are issued to recognize milestone occasions of exceptional significance.

- Certificates are only issued to current Seventh District residents or organizations within the District.

- One certificate will be provided per organization or individual per year.

- The honoree must have made a significant contribution to the Seventh District or the City of Los Angeles.

- You may not request a certificate for yourself.

- The Councilwoman's office reserves the right to rescind a certificate if false or misleading information was provided in the application.

- The Councilwoman’s office reserves the right to decline any certificate request.
Sign in to Google to save your progress. Learn more
Email *
Event Date *
The date that will be printed on the certificate
MM
/
DD
/
YYYY
The date the certificate will be needed *
MM
/
DD
/
YYYY
Honoree's Full Name (Write out name as you would like it to appear on certificate. For more than one honoree, list each on separate line) *
Name of the Organization ( if not affiliated with an organization, type N/A) *
Reason for the Honor ( if requesting a 'in memoriam' please include date of birth and passing) *
Requester's Name *
Requester's  Email *
Requester's Phone Number *
Requester's Organization ( if none, type N/A) *
Method of Delivery ( please select one) *
To receive a certificate by mail, provide a mailing address. ( This may take an additional 2 weeks to arrive)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of City of Los Angeles. Report Abuse
Google Forms