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2. Name of Requestor*
3. Street Address
5. City
6. State
7. Zip Code
9. Phone*
10. Email
11. Date of Request
    Date of Request
13. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
15. Electronic Signature
17. Review or Duplication

    1. Review
    2. Duplication

    1. Both

    I Request review or duplication (check applicable boxes) of the following records.
19. Records Requested*
    Important: You must identify or describe the records with sufficient specificity to enable the Township to Determine which records are being requested. Use additional sheets if necessary.
21. For Official Use Only:
    The fields below are for official use only. Please do not complete these fields.
23. Request Number:
24. Date
    Date
26. Approved
27. Date
    Date
29. Denied
30. Date
    Date
33. Request Reviewed By
35. Comments
37. Total Number of Reports
38. Total Number of Photographs
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field