OPRA Test

Requestor Information

First Name:MI:

Last Name:Company:Mailing Address:City:

State:

Zip:

Email:

Business Hours Telephone

Area Code:Number:Extension:

How you'd like to receive the requested information

Preferred Delivery:

Under penalty of , I certify that

I HAVE

I HAVE NOT

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

Please type your information request, to expedite your request (be as specific as possible.)

Payment Information

Fees for duplication of a government record in printed form are listed below. Maximum Authorized Cost

(Please make check payable to Treasurer, State of New Jersey)

Payment Method:

Fees:

Pages 1-10 $0.75 each

Pages 11-20 $0.50 each

Pages 21- $0.25 each

Delivery:

Delivery/postage fees Additional depending upon delivery type.

Extras:

Extraordinary service fees dependent upon request.

By selecting the Submit button, you certify that all information contained in this Government Records Request Form is true.