Free Public Record Request Form (ss-6075) - Tennessee

State of Tennessee

Public Record Request
Department of State
Division of Charitable Solicitations & Gaming William R. Snodgrass Tennessee Tower 312 Eighth Avenue North, 8th Floor (615) 741-2555 (615) 253-5173 fax

Name of Person / Organization Requesting Record: _________________________________________________ __________________________________________________________________________________________ Address: ___________________________________________________________________________________
(Street) (City) (State) (Zip)

Telephone Number: (___)__________ Fax Number: (

)___________ Email Address:__________________

______________________________________________________________
Information requested: _______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

______________________________________________________________
SIGNATURE

I certify that the information furnished in this Public Record Request is true and correct to the best of my knowledge.

_______________________________________________________

___________________

Signature of Person Requesting Information

Date

_________________________________________________ Print name

ss - 6075

RDA pending