(a) | . . . . Name (please print) | . . . . Signature | ||
. . . . Name or Organization, if applicable | ||||
. . . . Mailing Address of Applicant | . . . . Phone Number | |||
(b) | . . . . Date Request Made | . . . . Time of Day Request Made | ||
(c) | Nature of Request . . . . | |||
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(d) | Identification Reference on Current Index (Please describe) | |||
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(e) | Description of Record, or Matter, Requested if not Identifiable by Reference to the Bellingham Technical College Index | |||
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(f) | I hereby certify under penalty of perjury under the laws of the state of Washington that these requested records shall not be used to compile a commercial sales list. | |||
dated this . . . . day of . . . . . , 1992 at . . . . , Washington. | ||||
Request: approved . . . . | denied . . . . | Date . . . . | ||
By | . . . . Name | . . . . Title | ||
Reasons for Denial: . . . . | ||||
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Referred to . . . . | Date . . . . | |||
By | . . . . Name | . . . . Title | ||