INSTRUCTIONS: Complete this form and present in person at the front counter located in SEM I 2150.
Email request
s may be submitted to ecos@evergreen.edu or publicrecords@evergreen.edu
Requested by
Name of Requestor: Date of birth: Case or Ticket Number:
Mailing Address: Contact Phone #:
City: State: Zip:
Incident Information
Please specify your request by filling in and checking the appropriate box(es) below and add any additional information
that will help us locate the record(s) for you as quickly as possible. Failure to provide information sufficient to identify
the record(s) may cause a delay.
Date (or range) of incident: Time of incident: Address of incident:
Incident Report Police Call Printout Follow-up Other:
Additional Information to include Name and Date of Birth of involved person(s) if not you and type of incident:h
I prefer to receive these records in the following format:
Emailed to: Paper Copy
Please call/ mail when ready
View by appointment
I understand that Washington State Law (RCW 42.56) prohibits the use of lists of individuals for commercial purposes. If applicable
to this request, I hereby declare, under penalty of perjury pursuant to the laws of the State of Washington, that I will not use this
request for commercial purposes. If applicable, I also acknowledge that I am solely responsible for any consequences or damages
arising from my commercial use of the information I am obtaining.
Requestor’s Signature:
X
Date of request:
NOTE: It could
take up to 30 business days following acceptance of your completed request for you to receive an incident report or
response. Please also be advised records are subject to copying fees and are released pursuant to public records dissemination
statutes, including RCW 10.97; 13.50; 42.56; 46.52.
Official Use Only
Request received via: Counter Phone E-mail Fax Mail
Received by: Date rece
ved:
ssigned to: Comm. Supervisor Records Date assigned:
Date request completed: Date requestor notified:
Locations searched: RMS SECTOR Records Room
Date provided: # of pages:
The Evergreen State College
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SEM I 2150
Phone: (360)867-6832 Fax: (360) 867-6666
