OPRA Request

2. 

4. Requestor Information - Please Print

6. First Name

7. Middle Initial

8. Last Name

10. E-mail Address

12. Address1

14. City

15. State

16. Zip

18. Telephone

19. Fax

21. Preferred Delivery

    1. Pick Up
    2. US Mail
    3. On Site Inspect
    4. Fax
    5. Email

22. If you are requesting records containing personal information, please select one: Under penalty of N.J.S.A. 2C:28-3, I certify that I

    1. Have
    2. Have Not

    been convicted of any indictable offense under the laws of New Jersey, any other state, or the United States.

24. Signature

    You agree that by typing your name, you are electronically signing this document.

25. Date and Time
    Date and Time

    Date and Time

27. Payment Information

29. Maximum Authorization Cost

30. Select Payment Method

    1. Cash
    2. Check
    3. Money Order
31. 

33. Record Request Information

35. Please be as specific as possible in describing the records being requested. Also, 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.

37. 

39. 

41. .

    1. Yes, I am also requesting the documents under common law.

43. 

45. Please set forth your interest in the subject matter contained in the requested material:

47. 

49. 

51. 

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field