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* 1. Name:

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* 2. Organization Affiliation (if any):

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* 3. Address:

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* 4. Phone:

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* 5. Email:

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* 6. Rank the following City Services in order of priority (1 - 10):

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* 7. What Belmont city service do you value or rely on the most?

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* 8. Is there a city service you would like the City to improve or provide?

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* 9. Thinking more about the programs and services provided at Barrett Community Center, rank in order of priority (1-7):

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* 10. What are your top priorities for the future of Belmont’s Community Center? (Rank 1-5)

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* 11. Is there a service you would like the Community Center to provide?

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* 12. Any other input/feedback on city services or budget priorities?

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* 13. Questions/Comments?

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