_____________________________________________ _____________________
SOWELA TECHNICAL COMMUNITY COLLEGE
P. O. Box 16950
Lake Charles, La 70616-6950
PRIVACY REQUEST FORM
As provided for under the Public Records Act, La.R.S. 44: 1, a request may be received for
information from your payroll/personnel file.
You may elect to keep some of the information “confidential” and not subject to disclosure
under the Public Records Act. Please complete the section below and return this form to the
Department of Human Resources.
I _____________________________ (print name), social security number _________________
officially request that the categories of information checked below not be released to the
public without my permission:
Name
Local address
Permanent address
Telephone number
Cellular telephone number
Signature Date
Revised 5/15/2007
