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FOR INTERNAL USE ONLY
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2009-10-16 JCM
TOWN OF WAPPINGER
Application for Public Access to Records
FOIL REQUEST
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FOR DEPARTMENT USE ONLY
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Date Applican~~ontacted: /0 I !i. I / ()
D'Ie~~enied: _1_1_
Closed by: 1/ 6'-
Date Received by Dept
Department Head approval:
Date:
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Pages for a total of $
Notes:
Amount Due:
Name: 6A ~ Y A3 VI<. eN / ~
Address: /3 Y d{ /P ~~ /f ~ 'I 1'''0$ r 0 .
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Agency or firm: Ct:J~~W~~l. /.i/lA/;kr/<
Telephone #: (?/nJr99 - 9tJYlS" FAX#: ( )_-
Email address: (j I'f ~>' . ,8 vA (;1111< t?l (;, ,8/y 0 Y 4-...s ,,& ~ H
o check here if you are
requesting that the records
be mailed to this address.
SPECIFIC DESCRIPTION OF RECORD:
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FORMAT OF RECORD (if available)
I
o I request to be notified when I can come to inspect the record(s) described above
ri,./' I request copies of the records described above and agree to pay the cost of such records in
accordance with the fee schedule on the back of this application
o I request that the records be sent via e-mail to the address listed above
o I request that the records be faxed to the number listed above