2. Name of Department:*
   Please identify the department which records are being requested.
4. Date of Request:*
6. First Name:
7. Last Name:
9. Street Address:
11. City:
12. State:
13. Zip:
15. Email:
16. Phone Number:
18. Information Request:*
    Describe in detail the information you are requesting, be as specific as possible.
20. Medium Requested: Paper/Hard Copy or Electronic*
    Please note that there is a fee of $.10 is charged per page for a report, document or record that is 8.5" x 11" or 8.5" x 14". Photos, documents, audio recording or video is provided at a cost of $5 per CD. Postage, for the mailing of any record, will be an additional cost. If requesting records electronically, an email address will be required.
21. Notify me of costs exceeding:
23. Electronic Signature
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

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