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2. Purpose

   Use this form to send a general suggestion or comment to the Village of Amityville.

4. First Name
5. Last Name*
7. Business Name*
8. Email Address
10. Daytime Phone*
11. Fax Number
13. Address
15. City*
16. State*
17. Zip Code*
19. Describe Your Question or Comment*
21. Attach Picture or File
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field