Today's Date:

Requesting Firm or Individual:*

E-mail:

City:*

Address:*

ST:*

Zip:*

Telephone Number:*

Is this part of a pending criminal investigation or matter?*

Yes

No

Which agency or agencies responded?

Bismarck Police Department Burleigh County Sheriff's Department Mandan Police Department Bismarck Fire Department

Bismarck Rural Fire Department Mandan Fire Department Metro Area Ambulance Service

This Agency's Case Number or Event Number

Type of Incident:*

Date(s) Occurred:*

Time(s) Occurred:*

Location of Incident:*

By checking the yes box, you are authorizing staff from the Central Dakota Communications Center to contact you at the telephone number you have provided if additional information is required to locate your request.

Yes

No

Miscellaneous Information/Description/Parties Involved/Your Reference Number:

When the request is completed, you will be contacted to pick up the records. Payment is required at the time of pick up.

Please make checks payable to the "Central Dakota Communications Center". We do not accept payment by credit card.