(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 . . . .

 

. . . .

 

. . . .

(d)

Identification Reference on Current Index (Please describe)

 

. . . .

 

. . . .

 

. . . .

(e)

Description of Record, or Matter, Requested if not Identifiable by Reference to the Bellingham Technical College Index

 

. . . .

 

. . . .

 

. . . .

(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: . . . .

. . . .

. . . .

Referred to . . . .

Date . . . .

By

. . . .

Name

. . . .

Title