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2. 

   
   

4. Name of Requestor*
5. Organization*
7. If Requestor is an entity, name of authorized agent/representative*
9. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address*
17. 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.
19. Electronic Signature*

    By signing, I am stating that I have read and understand the Teller County CORA Policy.

21. Describe What Public Records are Requested*
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field