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2. Date of Request*
   Date of Request
3. Request #
5. Name (optional)
7. Address (optional)
9. Street Address
11. City
12. State
13. Zip/Postal Code
15. Phone or Fax Number/Email Address (optional)
17. Requested Records*
19. If these records are not readily available at the time of your request, please advise whether you desire to receive them by:

    1. Pickup
    2. Regular Mail
    3. Fax #
    4. Email
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21. 1. Receive an email copy of this form.
22. Email address

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23. Submit

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