Date Received Date of Res ID: 92258
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TKe document or documents lLstKe document or documents are not publLc records as provLded by 1 MUN,C,PAL PLA=A FREE+OLD N- 02 clerN@tZp.freeKold.nM.us FA;: 32-446-5 6 Requestor’s Name: 1 MUNICIPAL PLAZAFREEHOLD, NJ 07728 Requestor¶s Name: ____________________________________________________________________Requestor¶s Address: _____________________________________________________________________Requestor¶s E-Mail_____________________________________________________________________ Telephone [Cell] ( ) Telephone [Work] ( )___________________ Preferred Delivery: Email____ Fax____ UUp____ On-Site Inspection____ Please note that your preferred method of delivery will only be accommodated if the custodian has the technological means and the integrity of the records will not be jeopardized by such method of delivery. Records on the Specific Property: Address_________________________________ Block_______ Lot_______ Records Requested: (If you are requesting records containing personal information, please circle one: Under penalty of N.J.S.A. 2C:28-3, I certify that I HAVE/HAVE NOT been convicted of any indictable offense under the laws of NewJersey, any other state, or the United States. Applicant¶s Signature: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺDate: ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Letter size pages $0.05 per page, Legal size pages $0.07 per page, and CDs, DVD, etc. are actual cost of material