2. Date of Request
   Date of Request

   Date of Request
3. Request Number
   (To be completed by Records Officer)
5. First Name*
6. Last Name*
8. Company/Organization (If Applicable)
10. Address*
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Email Address
19. Requested Records Are For:*

    1. Review
    2. Copying

    1. Inspection, then copying of selected pages
21. Records*
    Please describe the public records you wish to receive. In order to expedite the search for the records, please be as specific as possible. Include, if possible, subject, titles, acronyms, and dates.
23. Signature of person making the request (if printing form for submission)
    The City will respond to this request withing five (5) business days (begins day after submitting request)
25. Do you agree?*

    By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
29. TO BE COMPLETED BY CITY OF WAYNESBORO
31. Date Received
32. Time Received
33. By:
35. Date Completed
36. Time Completed:
37. By:
39. Total Charges
40. Paid
41. Date
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

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