Military Discharge (Dd-214) Public Record Request Form - Graham County

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To: Graham County Recorder's Office
Request is hereby made to reproduce the following public record(s):
(Indicate the document number(s) and the name on the document. Attach on 8.5 '' x 11 '' sheet if necessary.)
Pursuant to ARS 39-121.03, the record(s) are requested to be used for what purpose?
You cannot use this record for a commercial purpose: Commercial Purpose is defined as: ''the use of a
public record for the purpose of sale or resale or for the purpose of producing a document containing all
or part of the copy, printout or photograph for sale or obtaining of names and addresses from such public
record for the purpose of solicitation or the sale of such names and addresses to another for the purpose
of solicitation or for any purposes in which the purchaser can reasonably anticipate the receipt of
monetary gain from the direct or indirect use of such public records.
I certify that all information provided is true and correct under penalty of perjury. I also agree that
the public record(s) will not be transmitted or resold to any other person or entity without specific
authorization from the Graham County Recorder's Office. I also certify that these records will only
be used for the sole purpose indicated about. I agree to delete all data acquired via this request from
my databases and all other electronic media forms upon completion of the purpose or use for which
this request is made. I agree not to hold Graham County liable for any inaccurate or incomplete
information I may receive. (*See Disclaimer on reverse)
(Please see reverse side for further explanation of authorized applicants)
Photo ID#:
Phone No:
Applicant's signature
State of Arizona, County of
day of
This instrument was acknowledge before me this
Signature of Notary Public
My Commission Expires:


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