Public Records Reproduction Request

Janice K. Brewer Governor State Of Arizona Board of Podiatry Examiners 1400 W. Washington, Ste. 230 Phoenix, AZ 85007 www.podiatry.az.gov (602) 542-3095 Fax: 542-3093 Sarah Penttinen Executive Director PUBLIC RECORDS REPRODUCTION REQUEST Name: _____________________________________________________________________ Date: ________________________ Address: _________________________________________________________________________________________________ Phone Number: ________________________________________ Alt. Number: ______________________________________ Records Requested: ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ (If you are requesting a Directory of licensed podiatrists, please see below regarding format.) These records will be used for : _____ Commercial Purposes OR ______ Non-Commercial Purposes. If the records are to be used for commercial purposes, specifically state those purposes: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ SWORN STATEMENT: I, _____________________, declare that I have read the information and instruction sheet accompanying this form and understand the contents therein. I further declare that the copies or other reproductions of the public records described above and which I have requested are to be used solely for the purposes stated above. I further declare that such copies or reproductions will not be used directly or indirectly for a different purpose other than described above. I further declare under penalty of perjury that the foregoing is correct and true. SUBSCRIBED AND SWORN TO me This ____ day of ________________. ________________________________________ Requesting Party's Signature ________________________________________ Notary Public My commission expires ______________ LISTING OF PUBLIC RECORDS REPRODUCTION REQUEST FEES Payment must be received in full with the hard copy of the request form. Requested documents/information will not be provided unless payment is received in full. Payment can be made in any form except credit card. ________ Directory of licensed podiatrists ________ Non-commercial purposes........................... ..................................................................... $0.25 per name ________ Commercial purposes........................... ........................................................................... $3.00 per name (Please contact the Board's office to obtain the number of currently licensed podiatrists and total Directory cost.) Please indicate desired format: ______ Hard copy via regular mail ______ Hard copy via fax ______ Excel format on CD sent by regular mail ______ Excel format via email to email address: ________________________________________________________ (Some formatting restrictions may apply. Contact the Board's office with any questions.) ________ Verification of Licensure (Includes copies of all disciplinary actions.)............................................................. $10.00 per licensee ________ Minutes & other documents............................................................................................................... $0.25 per page ________ Copies of Board records, documents, letters, applications, or files (subject to public information laws) ..................... $0.25 per page ________ Audio tape or computer disk containing information requested..................................................................... $25.00 (per request/per case) IMPORTANT! REVIEW INFORMATION ON REVERSE SIDE OF THIS FORM American LegalNet, Inc. www.FormsWorkFlow.com PUBLIC RECORDS REPRODUCTION REQUEST Information and Instructions REQUESTING PARTY: PLEASE READ AND NOTE THE FOLLOWING Pursuant to A.R.S. §39-121.03, Laws 1977, Chapter 54 §2 (effective 05/17/77), any person requesting copies, printouts or photographs of public records must provide a VERIFIED STATEMENT as to whether the use of such reproduction will be for COMMERCIAL or NON-COMMERCIAL purposes. A person providing a verified statement that the reproduction will not be used for a commercial purpose will be furnished such reproduction as a reasonable fee, not exceeding a commercial rate for like services. A person providing a verified statement setting forth the commercial purpose for which the reproduction will be used may be furnished such reproductions at the discretion of the custodian of records for a charge reflecting the following: 1. A portion of the cost to the State of Arizona for obtaining the documents or records to be reproduced; 2. A reasonable fee covering the cost of time, equipment and personnel in making the reproductions; and 3. The value of the reproduction on the commercial market. If the custodian of a public record believes that the commercial purpose of a reproduction is a misuse of public records or an abuse of the right to receive them, he or she may refuse a request for reproduction of such records for said commercial purpose and may request the Governor to prohibit the furnishing of reproductions for such commercial purposes by Executive Order. If an Executive Order is not issued within thirty days of the custodian's application, the requesting party will be furnished such reproductions for the commercial purpose set forth in his or her verified statement. "Commercial purpose" is broadly defined by the Act as "any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of such public records" (A.R.S. §39-121.03(E). "commercial purpose" includes copies of records for sale or resale and copies of printouts of names and addresses for purposes of solicitation of business. IMPORTANT: Subsection D or A.R.S. §39-121.03 provides that ...a person who obtains public records for a commercial purpose without indicating the commercial purpose or who obtains a public record for a non-commercial purpose or obtains a public records for a different commercial purpose or obtains a public record from anyone other than the custodian of such records and uses them for a commercial purpose shall, in addition to other penalties*, b