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