Fillable Lower Columbia College - Public Records Request Form

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Lower Columbia College - Public Records Request Form

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File type: PDF

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Request for Public Records
Date:
/
/
Fax:
E-
mail:
Requesting Party
Company or agency (if Applicable)
Address:
Telephone:
Requester Read and Sign
❒ 1. Inspect and/or
❒ 2. Receive copy of public record of:
Action by Public Records Officer
Date request received
Number of Pages
(25 cents per copy) $
❒ Request not granted pursuant to Chapter 42.56 RCW
Reason and disposition of matter:
Request Completed
Copies received
Requestor
Date copies mailed
Signature:
Public Records Officer
Date:
/ /
Date:
/ /
Revised – December 2016
LOWER COLUMBIA COLLEGE
Nolan Wheeler, Public Records Officer P.O.
Box 3010; 1600 Maple St.
Longview, WA 98632
Individual named above seeks to:
(Pursuant to WAC 132M-110)
The public records officer shall be responsible for implementing the College’s rules and regulations and regarding release of public records coordinating the staff
of the College in this regard, and generally ensuring the compliance with the public record laws under Chapter 42.56 RCW and as hereinafter amended.
I understand that I will be charged twenty-five cents per copy for all standard letter size copies I desire and
that other size/format publications are available at cost.
Signature Date
Time:
Nolan Wheeler, Public Records Officer • nwheeler@lowercolumbia.edu
1600 Maple Street • Longview, WA 98632
DECLARATION FOR NON COMMERCIAL
USE OF LIST OF NAMES
Printed Name
Mailing Address
City, State & Zip Code
Telephone
FAX Number
E-Mail Address
The undersigned, certifies and declares as follows:
1. I have requested access to and/or copies of the following public records from Lower Columbia
College:
2.
I understand that records I request from Lower Columbia College under the Public Records Act,
RCW 42.56 are not for commercial purposes.
3. I understand that the use for commercial purposes of said records may also violate the rights of
individuals named herein and may subject me to liability for such commercial use.
4. I have been informed that the Revised Code of Washington, RCW 42.56.070(9) prohibits
agencies from providing lists of individuals for a commercial purpose and understand that
violation of this certification constitutes false swearing under RCW 9A.72.040.
5. I understand that "for commercial purposes" means a business activity by any form of business
enterprise intended to generate revenue or financial benefit.
6. I understand that Lower Columbia College does not warrant nor in any way guarantee the
accuracy or completeness of its data.
7. Therefore, I do hereby certify and declare under penalty of perjury under the law of the state of
Washington that I will not use said records for commercial purposes and that, further, it is my
affirmative duty to prevent others from using said records for commercial purposes.
Signature Date
Date/ Place (city or county)
I have requested access to and/or copies of the described public records from Lower
Columbia College for the following purpose:
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Lower Columbia College - Public Records Request Form

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Completed 6 May 2020

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