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2. The following information is required to determine if the information you are requesting is public or not public data. If determined to be not public, additional information may be requested to determine if you can have access to the data.
4. Description of the information you are requesting (be specific)*
6. Date requested*
   Date requested
8. Requester First Name*
9. Requester Last Name*
11. Address*
13. City*
14. State*
16. Postal / Zip Code*
17. Country*
19. Phone Number*
20. Email
21. Representing*
23. Date of incident*
    Date of incident
25. Case number*
27. Location of incident*
29. When the report is ready, I would prefer*

    1. To have the report mailed to the address listed above
    2. To pick-up the report myself (We will contact you at the above phone number when the report is ready)
    3. To have the report emailed or faxed to the address listed above (By choosing this option, you agree to receive private data in an unencrypted email)
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field