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PDFWAC 132N-276-150

Appendix A—Form—Request for public record(s).

Request for
Public Record(s)
Clark College
Administrative Services
This form is to be used to initiate a request for copying or inspection of public records as prescribed in RCW 42.17.250 through 340. The form is to be completed and sent to the Clark College Administrative Services Dept.
Name (Please Print)
Name of Organization (If Applicable)
Phone Number
Mailing Address
Date and Time Request Made
Record(s) Requested:
Will this information be used for commercial purposes?          Yes _______    No _______ 
Instructions for Receipt of Record(s)
. . . .
(To be completed by Public Records Officer)
Date and Time Request Received
[ ]
All records subject to the request are provided with this response.
[ ]
The College will need days to respond to the request based on the following reason(s):
[ ]
The intent of your request needs to be clarified:
(Specific questions should be included here; e.g., what
time period? Does the request include personal information?)
Note: Failure to clarify the request will mean no further response).
[ ]
To locate and assemble the records.
[ ]
To notify third persons or agencies affected by the request.
[ ]
To determine whether any of the information request is exempt and that a denial should
be made as to all or part of the request.
[ ]
The request is denied based on the following exemption(s):
You may obtain review of the decision denying inspection by presenting a written request for review along with the written statement which sets forth the basis for denial to the President. The President’s review shall be deemed completed at the end of the second business day following the denial of inspection and shall constitute final agency action for the purpose of judicial review.
, Public Records Officer
Date and Time of Response:
Acknowledgment of receipt:
ADB 2233
[Statutory Authority: RCW 28B.50.140 and 42.17.250(1). WSR 96-12-041, § 132N-276-150, filed 5/31/96, effective 7/1/96. Statutory Authority: Chapters 28B.50 and 28B.10 RCW. WSR 89-12-024 (Order 89-01, Resolution No. 89-01), § 132N-276-150, filed 5/31/89; Order 77-3 d, § 132N-276-150, filed 8/29/77.]
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