WAC 67-10-180   Form 2 -- Request for photocopy of record(s).  

	. . . . . . . . . . . . Request number
	. . . . . . . . . . . . Date requested
	. . . . . . . . . . . . Date provided
	. . . . . . . . . . . . (Office use only)
WASHINGTON DEPARTMENT OF SERVICES FOR THE BLIND
Request for Photocopy of Record(s)

1. Name	4. Phone number
2. Address	5. Representing (if applicable)
3. Zip code	6. If urgent - date needed
Please state below the pages of the documents or records you wish to have photocopied. A reasonable standard fee for each page or record will be charged for this service.
I wish the following page(s) of documents or records to be photocopied and made available for my possession, I agree to pay a reasonable standard charge for this service.
I certify that the photocopies of records received as listed above will not be part of a list of individuals to be used for commercial purposes.

	Signed . . . . . . . . . . . .
	Date . . . . . . . . . . . .
Office use only

Number of pages copied . . . . . . @ . . . . . . . . per copy. Total charge . . . . . . . . . . . . . . . Amount paid . . . . . . . .

[Statutory Authority: 1983 c 194 § 18. 84-01-040 (Order 83-06), § 67-10-180, filed 12/15/83. Formerly WAC 67-14-180.]