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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:
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.
Signature of requesting person
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
My Commissions Expires:
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