Application for Internet Access to

APPLICATION FOR INTERNET ACCESS TO

RECORDS MANAGEMENT SYSTEM

Updated January 2010

The approval of this application is at the Clerk of the Circuit Court’s discretion. By signing this application the Subscriber acknowledges and accepts the terms and conditions of the Subscriber Agreement for Internet Access to Circuit Court Documents as incorporated by reference herein.

SUBSCRIBER: _____________________________________________

CORPORATE NAME: _______________________________________

INDIVIDUAL’S LAST NAME: ________________________________

INDIVIDUAL’S FIRST NAME: _______________________________

BUSINESS NAME (if applicable) ______________________________

STREET ADDRESS: ________________________________________

CITY/STATE/ZIP: ___________________________________________

PHONE NUMBER: __________________________________________

EMAIL ADDRESS: __________________________________________

UNITED STATES CITIZEN Y__ N___

SIGNATURE _______________________________________

I certify that the information above is true and correct.

I, ______________________________a Notary Public, do hereby certify that on this ___day of ________,  2010 the subscriber _______________personally appeared before me and swore and acknowledged to me that the statements contained therein are true and correct.

Notary Public, State of ____________________ County of ____________________

Typed Name or Printed: _________________________________________

My commission expires: _____________Registration Number: ________________

Notary Phone Number: _________________

For use by Circuit Court Clerk’s Office only

Subscriber ID: ___________________

Password ___________________

Expiration Date __________________