2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Fax Number
14. Description
    I, the person named above, hereby request the custodian of records for the _______________________Department of the City of Douglas to provide for inspection and/or copying or other reproduction the public record(s) which are specifically described as follows:
16. Certification
    I certify that the record(s) will be used for: ______ Commercial purpose ______ Non Commercial purpose ______ Claim for a pension, allotment, allowance, compensation, insurance or other benefits which is to be presented to the United States or a bureau or department thereof.
18. Signature
    _____________________________ Signature of requesting person
20. Commercial Certification
    COMPLETE THIS SECTION ONLY IF THE COPY REQUEST IS FOR A COMMERCIAL PURPOSE: Specifically state the purpose of your request: ________________________________________ _____________________________________________________________________________________ I, ______________________________________, declare that I have read A.R.S. 39-121.03 and understand its contents. I further declare under oath that the information I have provided on this form is true and correct. _________________________ Requesting party’s signature STATE OF ARIZONA ) County of Cochise ) ss SUBSCRIBED AND SWORN TO before me this __________day of _________________, 2012, by ______________________. _________________________________ Notary Public My Commissions Expires:
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22. Submit

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