On-Site Records Reproduction Request Form

REQUESTOR

Order Date (required):

Date Needed By (required):

Discovery Cut Off (required):

Name (required):

Firm (required):

Address (required):

City (required):

State: (required)

Zip (required):

Phone (required):

Fax (required):

Email (required):

Case Title (required):

Case Number (required):

Case Location (required):

if other please specify

Attorney File No. (required):

BATES Numbering Start # (required):

Attorney Representing (required):

if other please specify

SUBJECT

Please Obtain Records of (required):

Known AKA’s (required):

Date of Birth (required):

Social Security Number (required):

Date of Incident (required):

Records Needed from Dates Forward (required):

RECORDS

Records Needed (required):

if other please specify

Attached Authorization/ Subpoena

Attached Signature is on File

Please Prepare Subpoena  Yes No

Description of Records Sought (required):

INSTRUCTIONS

OPPOSING COUNSEL LIST OR MAILING LIST

Name:

Address:

City, State, Zip:

Telephone:

Fax:

Upload in document file if submitting morethan 1 list

RECORDS ARE LOCATED AT:

Name:

Address:

City, State, Zip:

Telephone:

Fax:

Upload in document file if submitting morethan 1 list

I understand the charge for the above service is non-refundable, non-revocable, and noncontestable. I waive my right of refund and/or to dispute the charge.

Authorized Signature of Credit Card Holder (required):

Date (required):

Enter Security Code:
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