2. First Name*
3. Last Name*
5. Phone Number*
6. Email Address
8. Address*
10. City*
11. State*
12. Zip Code*
14. Public Records Request Description*

    Please include sufficient detail to enable the agency to identify the records requested. This may include the custodian of the record, the name or title of the record, and the date or date range of the record(s).

16. I am seeking:*

    1. A copy of the record
    2. To inspect the record
17. Delivery format of the record

    What medium or format would you prefer (printed or electronic)

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19. 1. Receive an email copy of this form.
20. Email address

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