132G-276-900 - Appendix A - Form - Request for public record to the Shoreline Community College

132G-276-900. Appendix A - Form - Request for public record to the Shoreline Community College

APPENDIX "A"

REQUEST FOR PUBLIC RECORD TO SHORELINE

COMMUNITY COLLEGE

(a)

. . . . . . . . . . . .

Name (Please Print)

  

. . . . . . . . . . . . .

Signature

  

. . . . . . . . . . . .

Name of Organization, if Applicable

  

. . . . . . . . . . . .

Mailing Address of Applicant

. . . . . . . . . . . . .

Phone Number

(b)

. . . . . . . . . . . .

Date Request Made at the Shoreline Community College

. . . . . . . . . . . . .

Time of Day

Request Made

(c)

Nature of Request . . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

(d)

Identification Reference on Current Index . . . . . . . . . . . .

     

Please Describe

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

(e)

Description of Record, or Matter, Requested if not Identifiable by Reference to the Shoreline Community College's Current Index . . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

(f)

Purpose of Request if the Request is for a List of Individuals . . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

  

. . . . . . . . . . . .

Request: Approved . . . . . . . . . . . .

  

By . . . . . . . . . . . .

     

Date

  

Public Records Officer or his or her designee

Denied Date . . . . . . . . . . . .

     

Reasons for Denial: . . . . . . . . . . . .

. . . . . . . . . . . .

Referred to . . . . . . . . . . . .

Date . . . . . . . . . . . .

        

By . . . . . . . . . . . .

        

Public Records Officer or his or her designee

Statutory Authority: RCW 28B.50.140(13) and 42.17.260(5). 00-10-048, § 132G-276-900, filed 4/26/00, effective 5/27/00; Order 3-11:74, Appendix A (codified as WAC 132G-276-900), filed 4/26/74.

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