appendix "a"

request for public record to

state board for community and technical colleges

(a)	. . . .	. . . .
	Signature	Signature (Please Print)
	. . . .
	Name of Organization, if Applicable
	. . . .	. . . .
	Mailing Address of Applicant	Phone Number
(b)	. . . .	. . . .
	Date Request Made at State Board for Community and Technical Colleges	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 State Board for Community and Technical Colleges Index . . . .
	. . . .
	. . . .
	. . . .
	. . . .
Request: Approved		. . . .	By . . . .
		Date	Public Records Officer
Denied Date . . . .
Reasons for Denial: . . . .
. . . .
. . . .
Referred to . . . .			Date . . . .
			By . . . .
			Public Records Officer

[Statutory Authority: Chapter 28.50 [28B.50] RCW. WSR 98-23-052, § 131-276-990, filed 11/13/98, effective 12/14/98; Order 18, Appendix A (codified as WAC 131-276-990), filed 7/2/73.]

PDFWAC 131-276-990

Appendix A—Request for public record to state board for community and technical colleges.