By signing below, I certify that I am authorized by my organization to request this data and that
I/we acknowledge and understand the following:
1. The use is restricted to the purpose indicated above and for no other purpose.
2. Any geographic data files obtained are either the property of the City of Traverse City or
are files licensed to the City of Traverse City for dissemination of proprietary data via a
Data Licensing Agreement.
3. The City of Traverse City is not obligated to collect, assemble or compile data or
geographic information. If the information is not readily available, or is not available in the
requested format, the request may be denied in whole or in part.
4. This digital information is conveyed “AS IS” without any warranty of accuracy or fitness for
a particular purpose or of a recipient’s right of use.
5. Requester agrees not to sell, loan or otherwise convey said data to third parties in
any digital form.
Date __________________________________
Organization (Requester) _____________________________________________
Name (Print) _______________________________________________________
Authorized Signature _________________________________________________
Address ___________________________________________________________
___________________________________________________________
___________________________________________________________
Telephone number ______________________________
E-mail Address ______________________________________________________
Requester: Do not write below this line
GIS Coordinator Approval
Approved. Files will be provided as requested.
Approved in Part/Denied in Part. See Comments below.
Refused. Further information is required. See comments below.
Denied. See comments below.
GIS Coordinator Comments
________________________ _________________________ ____________ ______________
GIS Coordinator Printed Name GIS Coordinator Signature Date Phone Number
