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2. Name of Requestor*
3. Date of Request*
   Date of Request
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number:*
12. Email Addresss*

    Initial responses will be sent to the above e-mail address, so please check for accuracy

14. Complete Description of Record(s) Requested:*
16. Title of Records Requested (if known):
18. Date of Records Requested (if known):
    Date of Records Requested (if known): Start Date

    —

    Date of Records Requested (if known): End Date
20. Please Indicate the Format in Which you Prefer to Receive the Requested Record(s):*

    1. I prefer to receive the record by e-mail
    2. I prefer to receive the record in electronic format on a flashdrive or CD (may be subject to charge)
    3. I prefer to inspect the record
    4. I prefer to receive a photocopy of the record (photocopies may be subject to copy charges)

    Not all formats may be available for all record types

22. Note:

    To the extent any of the records provided are copyrighted, take notice that these records remain subject to copyright law. The use, reproduction, downloading or distribution of copyrighted materials and works may subject you to applicable penalties and damages under state and federal laws.

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

    This field is not part of the form submission.

26. Submit Submit and Print

* indicates a required field