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Public Records Request Form

  1. Village Hall
    3715 Clemmons Road
    Clemmons, NC 27012
    Phone: 336-776-7511
    Fax: 336-766-7536
  2. Preferred Method of Contact
  3. I Want To
  4. Please be specific. Information such as date range, department where records are located and document titles are helpful if known. Attach additional sheets if necessary.
  5. Requestor to Read & Sign upon Submitting Request
    I understand that Public Records requests and records themselves will be reviewed by either the Village Manager or Village Attorney prior to my receipt. Further, I understand I will be charged a copy/scan fee of $0.10 per single-sided, 8 ½ by 11 page (double-sided pages are $0.20); rolled plans vary from $5 to $7 per page. I also understand other sized copies are available at a higher cost.
  6. Internal Use Only - to Be Completed by Village Staff
  7. Staff must advise the Village Clerk, on or before day 5, if records are not able within five working days.
  8. Location of Records
  9. Reviewed By
  10. Result:
  11. Attach copy of receipt
  12. Leave This Blank:

  13. This field is not part of the form submission.