EmailMe Form - Public Disclosure Request

Name

First Last

Home Phone

### - ### - ####

Email

Mobile Phone

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Identification or description of records (include date, as best known)

Upon locating documents I request: (Choose one)

Date Desired:

MM / DD / YYYY

I will Pick up records when they are ready

Mail Records to me at my expense

Copy, data transfer, and postage fees will apply and must be paid before records will be delivered

*

Agree

I, the undersigned, do declare as follows: This request for public documents which contains lists of individuals will not be used for commercial purposes to contact or affect such individuals to facilitate, in any manner, profit-expecting activity. I understand that such use constitutes violation of Washington State Law RCW 42.56 and the privacy rights of such individuals. By my signature below, I agree not to use the above requested document(s) for commercial purposes, and I acknowledge an affirmative duty to prevent others from using such document(s) for commercial purposes.

NOTE: The Public Disclosure Act is for the purpose of providing existing documents/records, not for the purpose of gathering, sorting and/or creating new documentation. This department cannot respond to your request to inspect or copy a record unless this form and declaration of non-commercial use is completed.

Signature

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