1.

Agency making request:

 

a.

Name: . . . .

 

b.

Address: . . . .

        Street      City         State       Zip

 

c.

Telephone Number: ( . . . . . ). . . .

                   Area Code

 

d.

Official or employee who should be contacted concerning the application.

 

1) Name: . . . .

          Last           First           Middle           Title

 

2) Address: . . . .

            Street       City           State        Zip

 

3) Telephone Number: ( . . . . . ). . . .

                          Area Code

2.

Cite specifically the statutory or regulatory provisions which establish your agency as a governmental agency, and the provisions which indicate your agency's need for CHRI.

. . . .

 

State/

Federal

Statute

Chapter/Title

Number

Section

Number

Paragraph

Number

3.

Attach a copy of the above provision(s) to this application and indicate, by marking, the specific language upon which you base your request.

4.

State your agency's need for access to CHRI relative to the above cited provisions.

I hereby affirm that all facts and representations made in this document are true and accurate to the best of my knowledge, information and belief.

 

. . . .

Signature of person filling out form

 

. . . .

Title

 

. . . .

Date