Public Information Request

Date Submitted

MonthDayYear

Time Submitted

:HourMinutesAM/PM Option

Please fill in the following form and submit. As soon as your information is available you will be contacted by someone in the Office of Community and Media Relations. Please note that all fields marked with a (*) are required.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Alternate Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

Fax

Area CodePhone Number

Company or News Agency

Information Requested (Please be as specific as possible)*

Preferred method of delivery (choose one)

Picked up from the Office of Community and Media RelationsMailed to the address providedEmailed to the address providedFaxed to the number provided