TUNKHANNOCK TOWNSHIP

REQUEST FOR INSPECTION AND/OR COPYING OF NON-CONFIDENTIAL RECORDS. 

FAX REQUEST TO:  570-643-5469

*Please print clearly*

Date of Request: ____________________

Individual Making Request:  __________________________________________

Address:  _______________________________________________________

               _______________________________________________________

Telephone Number:  _______________________________________________

Description of Subject Matter:  _________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Dates of Subject Matter (if applicable):  __________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Instructions:  Pick-Up ______________  Fax To: _________________  Mail:  ___________________

Signature: (when request is fulfilled)  _____________________________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

FOR OFFICE USE ONLY

Copies:  ________________  Postage:  _________________  Disk:  ________________  Fax:  _______________

Total Amount Due:  _________________________

Date Request Fulfilled:  ______________________   Initials of Staff Member:  ___________________________

Date Information:  Picked Up:  ______________  Faxed:  ______________  Mailed:  _________________