Please print this form and complete as instructed.

City of Rochester

Records Access Application
(Please print or type)


Date:______________________________

Print Name:_________________________

Representing:________________________

Telephone:__________________________

Address:_____________________________

____________________________________

____________________________________

Signature:_____________________________


I hereby apply to inspect and/or copy the following record(s):
__________________________________

__________________________________

__________________________________

____________________________________

____________________________________

____________________________________


Return completed application to:

Records Access Officer
Bureau of Communications
City Hall, Room 202A
30 Church Street
Rochester, New York 14614
FAX (716) 428-7069

There is a $.25 per page charge for copying most records. For more information on public access to records, call 428-7135.

For agency use only
________________________________________________________________________

Approved

Denied

Record not Maintained by City

Record Access Officer:

____________________________________

Date:________________________________


For appeal only
________________________________________________________________________

If you wish to appeal the Record Access Officer's decision on your application for public access to records, sign below and send this form within 30 days to:

Corporation Counsel
City Hall, Room 400A
30 Church Street
Rochester, New York 14614-1295

I hereby appeal:

__________________________________________

Signature:

____________________________________

Date:________________________________

 


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