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Application for Public Access to Ke~'ds
FC)IL R EQ NEST
FQR DEPARTMENT Fj~E (JNLY
Date Received by Dept. ~ % 2~,~ `~
Department Head approval:
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Date Applicant Contacted: ~ f' 23~ L.~
Date F L fulfilled~or enied: ~/ ~~ !~
Closets by: __~~!_1d`~-==
Date: ~ ~ ~ ~ ~/
Notes:
Amount Due: ___ Pages for a total
~„ ~.
Name: ~ ~1 check here if you
Address: 1 l~ C~C,r~ ~ requesting that the records
_ t 0 c~~ be mailed to this address.
Agency or firn?: --
Telephone #: {`?t~') ~~' 9~tt7 FAX #: ( )
Email address: S L ~ r ~ T ~ PAt~p ~ ~ ~ C~m1~cT-i-~ C.~'~M.
-ECIFiC DESCR7f'TiGN OF RECORD:
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Ft.~~AT OF RECORD {if available)
I regctest to be notif ed w°hen 1 can come to inspect the records} described above
1 request copies of tfie records described above and agree to pay the cast of such retards in
acccordance with the fee schedule can the back ol"this application
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