One City Plaza – Norwich, NY 13815
Telephone 607- 334-1230 -- Fax 607-334-1208
Date of Request:
Specific Record Requested:
Date & Time of Incident (if applicable):
Specific Information Requested:
Name of Person Requesting Record:
Within five (5) business days the above request will be approved or denied.
Copies of approved records will be available @ $0.25 per each single page.
APPROVED ___________________ DENIED
Reason for Denial:
Signature: ____________________ Title: __________________ Date:
NOTICE: You have the right to appeal a denial of this application to the head of this