| Date . . . . . . . . . . . . |
Time . . . . . . . . . . . . |
| Name . . . . . . . . . . . . |
| Address . . . . . . . . . . . . |
| . . . . . . . . . . . . |
| Description of Records |
| . . . . . . . . . . . . |
| . . . . . . . . . . . . |
| . . . . . . . . . . . . |
| I certify that the information obtained through this
request for public records will not be used for
commercial purposes. |
|
. . . . . . . . . . . .
Signature |
| |
| Number of copies |
. . . . . . . . . . . . |
|
| Number of pages |
. . . . . . . . . . . . |
|
| Per page charge |
$ .25 |
|
| Total charge |
$ . . . . . . . . . . . . |
|