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2. County of Russell, Virginia
3. REQUEST FOR RECORDS PURSUINT VIRGINIA FREEDOM OF INFORMATION ACT
5. Requesting Party Information
7. REQUESTING PARTY NAME:
9. REQUESTING PARTY MAILING ADDRESS (Only information necessary to respond to this Request need be provided):
11. Address
13. City
14. State
15. Zip Code
17. Phone Number
18. Fax Number
20. Email Address
22. Information Request:
24. I HEREBY REQUEST COPIES OR ACCESS TO THE FOLLOWING RECORDS PURSUANT TO THE VIRGINIA FREEDOM OF INFORMATION ACT:
26. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature
30. Date of Request:
    Date of Request:
32. For County Use Only
34. Date Request Received:
    Date Request Received:
36. Received By:
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field