044
FOR INTERNAL USE ONLY
Received by:
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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
Date Received by Dept
Department Head approval:
/ 1
(init)
Date Appli/~ntacted: _ / _I _
DateFO~Ordenied,: ,1!) Idr 1 L
Closed by: ,--,'_
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Notes:
Amount Due:
Pages for a total of $
Name: 12of3~T 1//ft;(j)Vf~L
Address: I 3 A.J t tAl ~ (
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o check here if you are
requesting that the records
be mailed to this address.
Agency or firm:
Telephone #: <1lC() ~- l 2-( J,:, FAX #: (
Email address:
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SPECIFIC DESCRIPTION OF RECORD:
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FORMAT OF RECORD (if available)
o I request to be notified when I can come to inspect the record( s) described. above
o 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