MONMOUTH COUNTY REGIONAL HEALTH COMMISSION NO.1 |
1540 West Park Ave, Suite 1 |
Ocean, NJ 07712 |
Telephone (732)493-9520 Fax (732)493-9521 |
GOVERNMENT RECORD REQUEST FORM |
| All persons requesting access to government records must fill out this form and fax or mail the form to the Custodians Records Clerk at the address listed above. The custodian of government records must review the request and the requested documents before access is permitted to the document(s). If copies are requested, fees for documents to be copied must be prepaid. Checks must be made payable to the Monmouth County Regional Health Commission #1. Provided that the document requested is not in storage, access must be granted or denied within 7 business days of the request. Anyone denied access, may institute a proceeding to challenge the decision by filing an action in Superior Court; or in lieu of filing an action, may file a complaint with the Government Records Council established pursuant to Section 8 of P.L. 2001, c.404(C:471A-7). |
| BELOW INFORMATION MUST BE FURNISHED IN ORDER TO PROCESS YOUR REQUEST. REQUEST WILL NOT BE PROCESSED WITHOUT THIS INFORMATION. |
| Date of Request: __________________________________ |
| E-Mail address (if applicable): ________________________ |
| Name of Person Making Request: _____________________________________________________ |
| Address of Person making Request: ____________________________________________________ |
| Telephone Number: _______________________ |
| Fax Number: ____________________________ |
| Description of document(s) requested: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ |
| Signature of requestor: _______________________________________ |
DISTRICT USE |
| Denial date: _______________ |
| Denial reason (attach add’l page if necessary): _________________________________________________________________ |
| Approved date: _________________ |
| Copying fees: |
| Pgs 1 – 10 $.75 per page _____________x $.75 = _________________ |
| Pgs 11 – 20 $.50 per page _____________x $.50 = _________________ |
| Pgs 21 to end $.25 per page _____________x $.25 = _________________ |
| Estimated Document Cost: _______ |
| Estimated Delivery Cost: _______ |
| Estimated Extra Cost: _______ |
| Total Estimated Cost: _______ |
| Signature of Custodian: ____________________________ |
| Date Completed: _____________________________ |