Public Records Review/Duplication Request

2. Date of Request:*
   Date of Request:

4. First Name

5. Last Name

7. Address1

9. Address2

11. City

12. State

13. Zip

15. Telephone No.

16. I request (check applicable boxes) of the following records:*

    1. Review
    2. Duplication

17. Requested information to be:*

    1. Picked-up
    2. Faxed
    3. Mailed
    4. E-mailed

19. E-mail address

20. Fax No.

22. Important: You must identify or describe the records with sufficient specificity to enable the Township to determine which records are being requested.*

23. I certify that I am a legal resident of the United States of America:

    1. Yes
    2. No

Leave This Blank:


24. 1. Receive email copy
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

* indicates a required field