WAC 67-10-170   Form 1 -- Request for inspection of records.  

	. . . . . . . . . . . . Request number
	. . . . . . . . . . . . Date requested
	. . . . . . . . . . . . Date provided
	. . . . . . . . . . . . (For office use only)
WASHINGTON DEPARTMENT OF SERVICES FOR THE BLIND
Request for Inspection of Records

The information requested in Blocks 1 through 6 is not mandatory, however, the completion of these blocks will enable this office to expedite your request and contact you should the record you seek not be immediately available.

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1. Name	4.	Phone number
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2. Address	5.	Representing (if applicable)
- - - - - - - - - - - -
3. Zip code	6.	If urgent - date needed
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Below please state what record(s) you wish to inspect and be as specific as possible. If you are uncertain as to the type or identification of specific record or records we will assist you.


I certify that the information requested from the above record(s) will not be part of a list of individuals to be used for commercial purposes.

	Signed . . . . . . . . . . . .
	Date . . . . . . . . . . . .

[Statutory Authority: 1983 c 194 § 18. 84-01-040 (Order 83-06), § 67-10-170, filed 12/15/83. Formerly WAC 67-14-170.]