M:\City Clerk\Public Information requests\Request for public Records Application.doc Page 1 of 2
Request for Public Records
1. Contact Information
Applicant’s Information
Name: ______________________________________________________________________
Mailing Address: ______________________________________________________________
____________________________________________________________________________
Phone: ______________________________________________________________________
Fax number: __________________________________________________________________
Email: _______________________________________________________________________
Email: _______________________________________________________________________
Signature: ____________________________________________ Date: _____________
2. Requested Information
I request that you make available to me the following records -- (Applicant shall describe
records as specifically as possible. Where you are asking for records that cover only a
particular period, such as last year or a specific month, identify that time period):
If you know the subject matter of the records, but do not have additional information, use this
alternative. I request that you make available to me all records that relate to: (Applicant be as
specific as possible; include dates if you can.)
I wish only to view these documents at City Hall and am not requesting reproductions.
I am requesting reproductions of the above information.
3. Fees
Please let me know in advance of any research, reproduction or other fees if they will exceed
$________. (Insert amount you are willing to pay without additional information about the
documents. If you wish to know of any fees prior to reproduction, you may enter $0.)
4. Notification
When the estimate and/or records are ready, please notify me by: phone email fax.
