What records would you like sent back to you via email (Include as much detail as possible such as full names, dates, descriptions, etc...):

Please inform me of the cost of providing paper copies of the following records (Include as much details as possible such as full names, dates, descriptions. etc...)

Inform me of the approiate time during business hours for me to inspect the following records prior to obtaining copies

What records would you like to inspect before receiving copies (Include as much detail as possible such as full names, dates, descriptions, etc...):

For records that can not be emailed to me, please inform me by email of the portions that can be emailed and advise me of the cost for reproducing the remainder of the records requested

What records would you like paper copies of (Include as much detail as possible such as full names, dates, descriptions, etc...):

Please inform me of the cost of having the records supplied to me on a CD-ROM

If my request must be modified, I would prefer to be contacted by phone at this number:

Full Name:

Email Address:

Mailing Address:

If for any reason any portion of my request is denied, please inform me of the reason in writing and provide the name, address and email of the person or body to whom an appeal should be directed