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4. Requestor Information
6. First Name

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12. Email: *
14. Address1
16. Address2
18. City
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22. Type of Record Requested*

    Describe in detail the information you are requesting. Please be specific, include the Record Schedule Numbers and Titles from the appropriate Retention Schedule, if known):

24. Date Range of*
    Date Range of
25. Records Requested*
    Records Requested
27. Format Requested:*
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28. Requested Method of Delivery*
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32. Number of Copies Requested:*
33. Notify me of Duplication costs exceeding $
35. Signature

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