1

Contact Information

 *

Contact Information

Name:

Address:

Telephone Number:ext.

Email:

2

I, the undersigned, do hereby request to examine and/or copy those records maintained by the City of Effingham which pertain to:

 *

I, the undersigned, do hereby request to examine and/or copy those records maintained by the City of Effingham which pertain to:

examine

copy

3

Is the request being made by a commercial company?

Is the request being made by a commercial company?

Yes

No

4

Please specify department and records sought:

Please specify department and records sought:

5

I have read and understand the fees set forth in the "Schedule of Duplication". At my request, copies may be mailed to me via certified mail at $6.40 for the first ounce and $.20 per each additional ounce. I also understand that all fees must be prepaid.

I have read and understand the fees set forth in the "Schedule of Duplication". At my request, copies may be mailed to me via certified mail at $6.40 for the first ounce and $.20 per each additional ounce. I also understand that all fees must be prepaid.

I do want copies mailed to me at the above-listed address.

I do want documents emailed to me at the above-listed email address.

I do NOT want copies mailed to me at the above-listed address.

I do NOT want documents emailed to me at the above-listed email address.

6

Terms and Conditions Agreement 

Click here to view Terms and Conditions

I agree

7

Electronic Signature

Electronic Signature

Signature (First, Last)

Date (mm/dd/yyyy)

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