2. 
4. FEE $5.00 Per DVD
6. Name of Requestor*
7. Email Address*
8. Phone Number*
10. Purpose of Video*

    1. City Court
    2. General Session Court
    3. Circuit Court
    4. Other (explain)
11. If Other, please explain
13. Subject Name and/or Event Description
14. Date of the Event
    Date of the Event
16. MPD Event Number
17. Start Time of Event
    Start Time of Event
18. Number of Copies
    -- Select One --12345678910
20. Electronic Signature*
    By entering you name in the box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
21. Date Submitted*
    Date Submitted
22. Time Request Submitted*
    Time Request Submitted
26. The Section Below is for Internal Use Only
28. Video Request Form Received By (Operations Division)
    ________________________________
29. Date Received
    _______________
30. Video Requestor Notified BY
    ___Email ___Telephone ___Interoffice Mail
32. Date Notice Sent or Given
    _________________________
33. Video Copy(ies) Released To
    ____________________________
34. Receipt Number
    __________________________
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field