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2. Date of Request*
   Date of Request
3. Name of Person or Organization Making Request*
5. Address of Person or Organization Making Request*
7. City
8. State
9. Zip Code
11. Phone Number of Person Making Request*
13. Description of Request*
    Please describe the record(s) you are requesting.
15. Purpose of Request*

    Choose one that describes your intent with the requested records.

    1. Inspect the Record(s)

    1. Receive a Copy/Copies of the Record(s)
17. Number of Copies*
    Identify the number of copies you need.
19. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I Agree
21. Signature*
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field