Form Center

2. Village Hall
   3715 Clemmons Road
   Clemmons, NC 27012
   Phone: 336-776-7511
   Fax: 336-766-7536
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. Phone
14. Email
16. Preferred Method of Contact

    1. Email
    2. Phone
17. I Want To

    1. Receive Record Copies
    2. View Records
19. Public Records/Information Being Requested
    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.
21. 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.
23. Signature
24. Date of Request
    Date of Request
28. Internal Use Only - to Be Completed by Village Staff
30. This request was provided to:
31. Date
    Date
33. Staff must advise the Village Clerk, on or before day 5, if records are not able within five working days.

    1. Day 1
    2. Day 2
    3. Day 3
    4. Day 4
    5. Day 5
34. Location of Records

    1. On Site
    2. Off Site
35. Reviewed By

    1. Village Attorney
    2. Village Manager
37. Result:

    1. This Request Was Satisfied
    2. This Request Was Not Satisfied
    3. This Request Was Denied
38. Date
    Date
39. Reason
41. Acknowledgement of Receipt upon Completion of Request
42. Date
    Date
44. Staff Representative
45. Number of Copies
46. Fee
    Attach copy of receipt
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field