The district hereby adopts for use by all persons requesting inspection and/or copying or copies of its records the following form:

REQUEST FOR PUBLIC RECORD TO

COMMUNITY COLLEGE DISTRICT NO. 4

(a)	. . . . Name (please print)		. . . . Signature
	. . . . Name of Organization, if Applicable
	. . . . Mailing Address of Applicant		. . . . Phone Number
(b)	. . . . Date Request Made		. . . . 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 Community College District No. 4
	. . . .
	. . . .
	. . . .
Request:		APPROVED. . . .	DENIED. . . .	Date. . . .
By	. . . . Name		. . . . Title
Reasons for Denial: . . . .
. . . .
. . . .
Referred to. . . .			Date. . . .
By	. . . . Name		. . . . Title