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Public Records Form

  1. 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:

  2. 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.

  3. Signature

    _____________________________ Signature of requesting person

  4. 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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