Request for DVD of Riverside TV Programming (Print Only)

2. The cost DVD is $20. Payment is due at time of application submittal. Checks should be made out to the Village of Riverside. If a DVD cannot be made for any reason, the fee will be returned. Normally, DVDs will be ready within 15 business days; however, processing may take longer depending on the availability of staff. You will be contacted by the Village 1) if the DVD request is delayed and 2) when the DVD is ready.
4. Name of Applicant
5. Phone Number
7. Address
9. City
10. State
11. Zip Code
13. Name of the Program Recording
14. Email
16. Electronic Signature Agreement

    By checking the "I agree" box below, 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.

    1. I agree.
18. Electronic Signature
20. Initials of Employee Receiving Request
21. Date Received
    Date Received
22. Date notified by email
    Date notified by email
23. Fee Received

    1. Yes
    2. No
25. 2 Week Follow-Up Date
    2 Week Follow-Up Date
26. Date of Applicant Pickup
    Date of Applicant Pickup
28. Notes
Leave This Blank:


29. Print Only

* indicates a required field