REQUEST FOR PUBLIC RECORDS

Name:  ______________________________________     Date:  ____________

Address:  _______________________________________________________

                       (Street)                                                (City)             (State)   (Zip)

Phone:          Home:  ____________________                        Work:  _______________

Nature of Request:

            □          Opportunity to review records (no original record may leave

                        this office

            □          Copies of records

Please read and sign the following statement:

            I have requested public records for a noncommercial purpose.  I understand that if the records should be used for a commercial purpose, a verified statement of the purpose must be submitted per A.R.S. §39-121.03.

_________________________                ________________________________

                    Date                                                               Signature

Notice:  A fee of $0.25 will be charged per page.

Records Request (please be as explicit as possible as to the records you desire):

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