The director hereby adopts for use by all persons requesting inspection and/or copying or copies of the department records, the form attached hereto as Appendix A, entitled "Request for public record."

appendix a

request for public records

Name of Requestor:
Address:		Phone:
Date of Request:		Time of Request:
Nature of Request:
1.	Index Reference . . . .
2.	If not identifiable by reference to the index, then describe the document(s) in detail. . . .
	. . . .
	. . . .
	. . . .
Signature		. . . .

For Office Use Only:
(1)
Request Granted □		Record Withheld □	Record Withheld In part □
(2)	If withheld, name the exemption contained in section 31, chapter 1, Laws of 1973, which authorizes the withholding of the record or part of record: Subsection (1) ( ).
(3)	If withheld, briefly explain how the exemption applies to the record withheld.
(4)	If request granted, time . . . . . . . , day . . . . . . . . .

PDFWAC 415-06-110

Adoption of form.