Public Records Request Form C
Aggregate Requests
City of Cookeville Police Department
10 E. Broad Street, PO Box 849
Cookeville, TN 38503
Business Name: ____________________________________________________________
Address: __________________________________________________________________
Phone Number: ____________________________________________________________
FAX: ______________________________ Email: _______________________________
Full name of employee(s) authorized to submit requests:
Email will be the primary form of communication. The fee schedule shown below will apply:
$0.15 per page for letter and legal size black and white copies.
$0.50 per page for letter and legal size color copies.
$5.00 for each compact disc containing digital data (e.g., still pictures or video).
Labor when research or redaction time exceeds one hour.
The actual costs assessed by an outside vendor if such a vendor is needed to provide the
research or redaction services necessary to provide the record requested.
Payment can be made by cash or check payable to the City of Cookeville. The check can be sent to the
address shown above.
Please Initial:
I give permission for the Cookeville Police Department to send me a monthly invoice to be paid within
15 days of receipt for reports that I request. Initial ___________
This request will be honored as promptly as possible. However, I acknowledge that my request may be
delayed for up to seven business days. Initial ___________
__________________________________ __________________________________ ___________________
Signature of Requestor & Date Signature of Employee Receiving Request Date Received
Directions for Completing the Public Records Request Form C
Business Name: The name of the business making multiple future records requests.
Address: Address including city and ZIP code of the requesting business where records can be sent.
Phone: Phone number through which the requesting business can be contacted.
FAX: FAX number for the business if applicable.
E-mail Address: E-mail address through which the business can be contacted and records sent.
Names of Authorized Representatives: List of the full names of employees authorized to make requests for the
Acknowledgement of Monthly Billing Schedule: The requestor must initial their acknowledgement of the timely
payment of a monthly invoice for multiple records requests.
Acknowledgement of Seven Day Notification Period: The requestor must initial their acknowledgement of the
seven-day limit to respond to the request as specified in the TPRA.
Requestor Signature and Date: The requestor must sign their request and provide the date the request form was
submitted to a record custodian.
Employee Signature and Date: The employee receiving the request must sign the form and provide the date the
request was received.