| Date of Request . . . . . . . . . . . . | Time of Request . . . . . . . . . . . . |
| Name . . . . . . . . . . . . | |
| Address . . . . . . . . . . . . | |
| . . . . . . . . . . . . | |
| Description of Records: | |
| . . . . . . . . . . . . | |
| . . . . . . . . . . . . | |
| . . . . . . . . . . . . | |
| . . . . . . . . . . . . Signature |
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| Number of pages to be copied | . . . . . . . . . . . . | ||
| Number of copies per page | . . . . . . . . . . . . | ||
| Charge per copy | $ | . . . . . . . . . . . . | |
| Special copy work charge | $ | . . . . . . . . . . . . | |
| Staff time charge | $ | . . . . . . . . . . . . | |
| Total charge | $ | . . . . . . . . . . . . | |