2. First Name*
3. Last Name*
5. Company Name (if applicable)
7. Address 1*
9. Address 2
11. City*
12. State*
13. Zip*
15. Contact Number*
16. Email Address*
18. Description of Public Record(s) Being Requested:*
    Be as specific as possible. Failure to provide specific information will result in the delay of fulfilling your request. Please provide all information you have concerning your request.
20. Department*

    1. Administration
    2. Finance
    3. Fire
    4. Parks

    1. Planning
    2. Public Works
    3. Police
    4. Other
22. Signature of person making the request
    You may fax this form to the Town Clerk at 704-896-2462 or mail to PO Box 399, Cornelius, NC 28031
24. 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
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27. Email address

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