You must have JavaScript enabled to use this form. Requestor Contact Information Name of Requestor Phone Number Email Requestor's Job Title/Position Name of office/organization Purpose of Certificate Honoree(s) Information Name on Certificate (if multiple, please attach file below instead) Suggested language/Awardee’s Bio (if multiple, please attach file below instead) If multiple individuals, please upload document with names and bios One file only.200 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Date Needed By Request a joint certificate from our office and Sen. Arreguín's office How would you like the certificate to be presented? Mailing Address Presented by Asm. Wicks Office Please provide event details in our meeting/event request form (https://scheduling.assembly.ca.gov/a14) after submitting the Certificate Request. Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code