Appendix "A"

Request for public record to

Community College District No. 22

(a)

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Signature

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Signature (Please Print)

 

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Name of Organization, if Applicable

 

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Mailing Address of Applicant

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Phone Number

(b)

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Date Request Made at

Community College District No. 22

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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 Community College District No. 22's Current Index . . . .

 

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Request: Approved . . . . .

By . . . .

 

Date

 

Public Records Officer

Denied Date . . . .

 

Reasons for Denial: . . . .

. . . .

. . . .

Referred to . . . . . . . . . .

By . . . .

 

Date

 

Public Records Officer