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R�2UCST FOR RECORDS <br /> CITY CLERK'S OFFICE • <br /> • EVERETT, 1�ASHIi�GT0t7 <br /> � Print ' �//_ <br /> Na�e til/ ` lQ Signature ���� ""lG,� <br /> Address , �/, Y���9 ' �7 q�/ <br /> � ���-1 t���e C .Q p���C, Telephone �� 2 _/ 2 / b <br /> „rT Number <br /> Records ,/I� ,� i' .�' `/O/�-� y.�1�� Cr�n,���ur✓ <br /> Requested .!/ litS �^ <br /> ! <br /> . Request ` � � � • <br /> Recv6. by � �Date ���gC�_Time <br /> • ' gn ture • <br /> * *• Request � Received <br /> - forwarded to By. • <br /> Department <br /> ** Response Due Date <br /> ** Department receiving the request should attach information requested <br /> or a statement as to why the record is not being dispensed and <br /> return to the City Clerk for issuance to requestor. (Ord. 313-74) <br /> ACTION TAY.EN ON RECORD <br /> REQUEST <br /> Delivered Date No. Pages Certified <br /> Exempt Time No. Copies <br /> Attachments g��loyees Sign• <br />