REQUEST FOR PUBLIC RECORDS
To:	Public Records Officer						date of request		time of request
	Centralia College						. . . .		. . . .
public records or information requested								requested by
							name:
							. . . .
							organization:
							. . . .
							mailing address:
							. . . .
							. . . .
							. . . .
							requester read and sign
							. . . .
completed by public records officer				acknowledgment of receipt			I understand that I must abide by the rules and regulations published by Centralia College for the protection of public records, a copy of which I have read and understand.
no. of copies			amount received		date of receipt			time of receipt
. . . .			. . . .		. . . .			. . . .
public records officer signature						recipient's signature
. . . .						. . . .
reason if unable to comply:							I understand that I will be charged per copy for all standard letter size copies I desire and that other size publications are available at cost.
							. . . .
							requestor's signature
Public records of Centralia College are provided for inspection and copying subject to the following regulations:
WAC 132L-276-120 Protection of public records.
(1)		No person shall knowingly alter, deface, or destroy public records of Centralia College.
(2)		Care and safekeeping of public records of Centralia College, furnished pursuant to a request for inspection or copying, shall be the sole responsibility of the requestor.
(3)		Records furnished for public inspection or copying shall be returned in good condition and in the same file sequence or organization as when furnished.
(4)		Boisterous or otherwise disruptive conduct by those requesting public records of Centralia College shall not be permitted.
I have read, understand, and will comply with the above-stated regulations.
					. . . .
					Requestor's Signature and Date

PDFWAC 132L-276-900

Appendix "A"—Request for public record to Centralia College.