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Town of West Seneca Naming and Dedication Request Compliance Checklist Facility/Location: ____________________________ Proposed Name/Dedication: ____________________ Honoree(s): _________________________________ Sponsoring Organization: _____________________ Date Submitted: _____________________________ Committee Review Date: ______________________ I. Eligibility Requirements Requirement Yes No N/A Comments Individual made significant contribution benefiting the ☐ ☐ ☐ Town, Western New York, New York State, or the United States. Accomplishments are well documented. ☐ ☐ ☐ Principal legacy is clearly identified. ☐ ☐ ☐ Principal legacy aligns with Town mission, vision, ☐ ☐ ☐ values, and beliefs. Individual has been deceased at least two (2) years. ☐ ☐ ☐ Waiting period waived by Town Board motion (if ☐ ☐ ☐ applicable). II. Proposed Facility Eligibility Requirement Yes No N/A Comments Facility is owned or maintained by the Town. ☐ ☐ ☐ Facility qualifies under policy (building, park, ☐ ☐ ☐ structure, equipment, roadway, etc.). Dedication is appropriate for the facility type. ☐ ☐ ☐ Name does not create confusion with existing Town ☐ ☐ ☐ facilities. III. Written Application Requirements Requirement Yes No N/A Comments Request submitted in writing. ☐ ☐ ☐ Submitted by sponsoring Town entity. ☐ ☐ ☐ Detailed justification provided. ☐ ☐ ☐ Historical background included. ☐ ☐ ☐ Signage description included. ☐ ☐ ☐ Dimensions, design, and estimated costs included. ☐ ☐ ☐ Funding source identified. ☐ ☐ ☐ Applicant agrees to bear Town-incurred costs. ☐ ☐ ☐ Page 13 of 182