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2. Requestor Information
4. First Name*
5. Last Name*
6. Company
8. Address
10. City
11. State
12. Zip Code
14. Email*
15. Phone
16. Preferred Delivery

    1. E-Mail
    2. On Site
    3. Pick Up
    4. US Mail
18. Record Request Information

    To expedite the request, be as specific as possible in describing the records being requested. Also, please include the type of access requested (copying, inspection, or examination); and if data, the medium requested.

22. Payment Information
    • Fees: Copies @ $0.10/page
    • Electronic Records: Shall be provided free of charge, but agency may charge for cost of media, programming, clerical, supervisory assistance and / or substantial use of information technology.
    • Delivery: Delivery / postage fees additional depending upon delivery type.
    • Additional Charges: May be charged if extraordinary time  effort required, depending upon request.
24. Maximum Authorized Cost
25. Select Payment Method

    1. Cash
    2. Check
    3. Money Order
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field