EmailMe Form - SLFPA-W Public Records Request Form

Note: identify the documents as specifically as possible and include a date range for each request.

I request that a copy of the following document(s) be provided to me:

Duplication Fees (Check or money order only. DO NOT send payment with this form. SLFPA-W will evaluate your request and contact you concerning fees.):

• $0.25 per page
• $10.00 surcharge for every 100 pages copied
• $1.00 per page sent via facsimile (only for requests of 20 pages or less)
• $5.00 per tape for transcription recordings
• $10.00 per CD copied
• $5.00 per certification

Please confirm Fee Schedule

I also include information at which I can be contacted if necessary to discuss any aspect of my request.

Name *

First Last

Company Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email Address
xxxx@xxxx.xxx *

Confirm Email