100B Drakes Landing Road, Suite 250 Greenbrae, CA 94904 (415) 464-2090

All Fields are Required

Application for Inspection & Copying of Public Records

Every person desiring to inspect public records of Marin Healthcare District shall first complete this Application for Inspection & Copying of Public Records form. Please complete all fields and click the submit button at the bottom. Your application will automatically be emailed to mariacountouriotis@marinhealthcare.org. If you have any questions, please contact Maria Countouriotis at (415) 464-2090.

Date:

Applicant Name:

Street Number: Street Name: City:

State: Please Select Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa, Canada, Europe Or Middle East Armed Forces Americas (Except Canada) Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip:

Applicant telephone number: ,-

Applicant email address: Check Here to Receive a Copy of This Request via Email.

Within ten (10) days of receipt of an application, the District shall determine whether the application seeks identifiable public records and whether to comply with the application. The District shall immediately thereafter notify the person submitting the application of the District’s determination and the reasons therefore. In case of “unusual circumstances,” the District may extend the ten (10) day time limit by providing written notice to the person making the application. For a complete text of the Marin Healthcare District’s procedures for inspection and copying of public records, please visit our website at www.marinhealthcare.org (under About MHD/Operational Documents) or contact our office to ask for a copy.

Does Applicant wish for document to be mailed or emailed to him/her? Please Select Yes No

Does Applicant wish to inspect records at the Marin Healthcare District office? Please Select Yes No If yes, in conformity of District guidelines, list date Applicant would like, if possible, to inspect records at Marin Healthcare District:

There is a charge of $0.25 per photocopied page. Does Applicant desire a photocopy of the above requested records? Please Select Yes No

There is a charge of $10.00 per duplicated audio tape. Does Applicant wish for a duplicate audio tape(s)? Please Select Yes No

Description of records Applicant desires to inspect (please be as specific as possible):