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* - denotes required fields

I hereby request the right to inspect, or obtain copies of, the following public records of the Village: Describe in detail records requested and information you are seeking. Include applicable time periods:

* Records Requested from:

Form Records:

If necessary attach a separate sheet:

Select 'yes' here if request is for a commercial purpose. A commercial purpose means the use of any part of the public records or information derived from the records in any form, for sale, resale, or solicitation or advertisement for sales or services.

I agree to pay the charges for reproducing the documents as outlined in the Guidelines for Submitting a Request for Records. If the services of an outside vendor are required to copy any public record, I agree to pay the charges that the Village incurs in connection with such copying fees (fees may be payable in advance).

*Printed Name:
Representing Name:
Daytime Phone:
*Zip Code:

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