00401/15/2013 13:03 8456917229 PROFESSIONAL SPEECH PAGE 02
FOR INTERNAL USE ONLY
Received by: Christine Fulton ^
Jessica Fulton
Date Received: C / ~ /
FOIL Ser. #:
DEP.AR'TN~NT:
ASSESSOR U
ACCOUNTING ^
CODE ENFORCEMENT n
PLANNJ,NG ^
ZONING 0
FIRE INSPECTOR n
HTGT.-IWAY ^
RECENER OF TAXES n
RECREATION ^
SUPERVISOR
TOWN CLERK )Y(
WATER/SEWER
DOG CONTROL OFFICER L]
TOWN ENGiNE.ER C7
TOWN ATTORNEX L7
2009-10-16 JCM
TOWN O~ V~A.P~'~TGER
Application for Public Access to Records
F'OI,L REQ~JEST
FOR DEPARTMENT USE ONLY
Date Received by Dept ~ / ~~~
Dcpartmenl Head approval:
(init)
Date Applicant Contacted: // ~~
Date FOTi. I.fil.le r denied: ~/ ~ /
~n
Closed by:
Date:
Notes:
Amount Due:
Pages for a total of $
Name: /Y1 i Tae ( Pee eLl check here if. you are
Address: r, y3 Ui n~_a/?~_~vf vtut.er requesting that the records
~h ! y ! ~~' be mailed to this address.
Agency or ftrrn: '
Telephone #: (p~{~'") C4 9' ! -~S~f a FAX #: ( ) -
Email add.ress:__p,~_C.t^ G o ~?T l~~l ~ ~ NE,JVEt-
SPECIFIC DESCRIPTION OF RECORD:
IUREd wa-~e.r -F~sf -~,
vv ~ ~-vim. ~y~ ~vy
FORMAT OF RECORD (if available)
^ I request to be potilled wheo I cam come to inspect the record(s) described above
^ I request copies of th.e records described above and agree to pay the cost of such records in
accordaacc with the fee schedule vn the back of this application
'~ I request that the records be sent via e-nnai.l. to tb~c address listed above
^ I request that the records be Eased to the number listed above