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2. First Name
3. Last Name
5. Phone Number
6. Fax Number
7. Email Address
9. Type of Record Required: *
11. Address/Parcel NO. of Subject Property*
13. How would you like to receive this information?*
    -- Select One --EmailBlack & White Copy ($0.25 / page/ per side)Colored Copy ($0.50 / page/ per side)Fax

15. Personnel assistance in processing requests shall be charged a rate of $20.00 per hour or portion thereof, with a minimum charge of $20.00. Payment will be collected prior to providing request.

17. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit Submit and Print

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