EOHHS-DTA

Name of requestor(Required)

First Last

Please enter your first and last name.

Name of Organization(Required)

List the name of your business/organization here.

Requestor Email Address(Required)

Enter your email address here.

Request Date

Enter todays date.

Briefly describe and summarize the public records request:(Required)

Use this section to provide details/specifics of your public records request.