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YAKIMA
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COLLEGE
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Request Number: _____________
Yakima Valley College
PO Box 22520 · Yakima, WA 98907-2520
509.574.4635 · Fax 509.574.4638
Email: mjensen@yvcc.edu
REQUEST FOR PUBLIC RECORDS
Name of Requester Date of Request Time of Request
Representing (if applicable) Email address Telephone
Street Address City State/Zip Code
Please be as specific as possible in defining the records you wish to see. If you do not know the specific name of the records you desire,
indicate by a general written description of the type and content of information you wish to locate. Where possible, indicate limiting
dates, topic, and person(s) referenced. Attach additional sheets if necessary. (An additional page is available at the end of this form.)
I choose to inspect the records at no charge before selecting copies.
I choose to request reproduction of the records.
I hereby certify that if a list of individuals is provided to me by Yakima Valley College, it will neither be used to promote the election of an
official or to promote or oppose a ballot proposition as prohibited by RCW 42.17.130 nor for commercial purposes or to give or provide
access to materials to others for commercial purposes as prohibited by RCW 42.56.070 (9). I further understand that I will be charged 15
cents per page for all standard and legal sized copies reproduced.
Requester's signature:
Date:
OFFICE USE ONLY
III. DISPOSITION OF REQUEST
Request referred to: Name/Department Date Sent
1.
Office in Custody of Record 2.
3.
ACKNOWLEDGMENT SENT
D
ate: By:
Charge: Requester must pay in advance by check made payable to Yakima Valley College. Remit to Cashier, Deccio Higher Education Center, Yakima
Campus. Upon receipt of check, requested materials will be released from the Public Records Office.
No charge; the request was less than 20 pages.
___________ Copies @ 15¢ per page for a total of $____________.
REQUEST CLOSED
Date: By:
Reasons for Closure:
If you need this publication in an alternate format, plea
se call 509.574.4635 or email mjensen@yvcc.edu. Persons with hearing loss can
call 509.574.4677.
