CITY OF JOHNSTOWN

                APPLICATION FOR ACCESS TO PUBLIC RECORDS

TO:  RECORDS ACCESS OFFICER

DATE: _____/_____/_____ 

         NAME OF DEPARTMENT: ________________________________________________________________________________________________________________

         ADDRESS: ______________________________________________________________________________________________________________________________

        I HEREBY APPLY TO INSPECT THE FOLLOWING RECORDS ($.25 per page):  _________________________________________________________________

         ________________________________________________________________________________________________________________________________________

         ________________________________________________________________________________________________________________________________________

                                                                           
  Signature:  _____________________________________________                                                                                                                                            

 Print name: ________________________________________________________________  Phone:  _______________________________                       

 Mailing address: _____________________________________________________________________________________________________                                                   

                             ______________________________________________________________________________________________________                                                                          

___APPROVED  
___DENIED (CHECK REASON(s) BELOW):
            ___Confidential Disclosure
            ___Part of Investigatory Files
            ___Unwarranted Invasion of Personal Privacy
            ___Record of which this agency is Legal Custodian cannot be found
            ___Record is not maintained by this agency
            ___Exempted by Statute other than the Freedom of Information Act
            ___Other (specify): ___________________________________________________________________________________ 

                                                      _______________________________________        _________________________        _____/_____/_____          
                                                                               SIGNATURE                                                    TITLE                                      DATE 

 NOTICE TO RIGHT OF APPEAL:  

YOU HAVE THE RIGHT TO APPEAL A DENIAL OF THIS APPLICATION TO THE HEAD OF THIS AGENCY (_______________________________at __________________________________________),WHO MUST FULLY EXPLAIN HIS REASON (S) FOR SUCH DENIAL, IN WRITING, WITHIN SEVEN (7) DAYS OF RECEIPT OF AN APPEAL. 

 I HEREBY WISH AN APPEAL:  _____________________________________________               _____/_____/_____           
                                                                           SIGNATURE                                                       DATE