File: KBA-FI
REQUEST FOR PUBLIC RECORDS
STAFF USE ONLY
Date Request Received: _____________________
Request was made (check one):
___ By requestor on this form
____ By telephone
____ In writing other than on form
______ (attach original request)
Date Response Sent: _______________________
(attach copy)
Identification Verified
Type: _____________________________________
Number: __________________________________
Date Inspection Made: _______________________
(attach record)
Itemized Cost Statement Attached |
Name _________________________________
Address _______________________________
______________________________________
______________________________________
Phone ________________________________
I am a (check one):
_ Citizen of the Commonwealth of Virginia
_ Member of Press Referenced in 2.2-3704
____ News Organization ___________________
OFFICIAL PHOTO IDENTIFICATION
MUST BE PRESENTED PRIOR
TO INSPECTION OF RECORDS
OR RECEIPT OF ANY COPIES
(PHOTOCOPY ACCEPTABLE WITH
MAILED/FAXED REQUEST)
I am requesting access to the following records (please be as specific as possible, and attach additional paper if necessary):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Reasonable costs for copying search and computer time may be assessed in connection with this request. A current schedule of costs appears in Regulation KBA-R.
Specify format desired (if available):
Photocopies E-mail (give address):______________________
Website posting other (please specify):_____________________
Check this box to request an advance determination of cost.
_____________________________________ ____________________________
Signature Date
RETURN COMPLETED FORM TO:
BUENA VISTA CITY PUBLIC SCHOOLS
2329 CHESTNUT AVENUE, SUITE A, BUENA VISTA, VA 24416