Confidentiality Statement - Boards & Commissions

2. To: Cedar Hill City Secretary

4. From:

   Please put board name here.

6. From this date forward, I hereby request that public access to personal information in the custody of the City of Cedar Hill, Texas that relates to my:

8. Please list the numbers and addresses.

10. Home Address:*

    1. Be allowed
    2. Not be allowed without my written consent

12. Home Telephone Number:*

    1. Be allowed
    2. Not be allowed without my written consent

14. Business Telephone Number:*

    1. Be allowed
    2. Not be allowed without my written consent

16. Cell Phone Number:*

    1. Be allowed
    2. Not be allowed without my written consent

18. Email Address:*

    1. Be allowed
    2. Not be allowed without my written consent

20. Information that reveals whether I have family members:

    1. Be allowed
    2. Not be allowed without my written consent

22. (Please check the appropriate response for each item listed above)

24. First and Last Name:

25. Signature:

27. Date:
    Date:

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field