WSTIP Request For Public Records

Request for Public Records: Please type or print clearly. If you do not complete this form, a WSTIP employee will contact you to obtain the information requested. Therefore, it is important to leave at least one telephone number or email address where you can be reached.

Name of Person Making Request

First NameLast Name

Name of Organization (if applicable)

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Additional Phone Number

Area CodePhone Number

Email*

example@example.com

Date and Time of Request*

DateHourMinutesAM/PM Option

Please describe the records you are requesting. If you know the title of the document(s), the date of the record(s), or any other identifying characteristic that would assist us in locating the record(s) requested, please indicate.

Please select one:*

Requesting document copies/duplicates. I understand and agree to pay the duplication charges.Requesting to view documents; I wish to make an appointment. No charges associated with viewing documents. Duplication charges apply if you request copies of viewed documents.

Method by which you would like to receive the copies/duplicates you have requested (if other arrangements are needed, please contact the Public Records Officer):*

Call me and I will pick up in personEmailed to me (if files are too large to email, WSTIP will contact you to make otherarrangements)

Charges: Actual cost may include sales tax when referred to an outside vendor for copying. A deposit may be required. A Summary of Applicable Charges is available upon request, prior to copies being made. Viewing records at the WSTIP Office is free of charge.

Photo Copies or Printed Electronic Records $0.15 per page

Scanned Records $0.10 per page

Four (4) Electronic Files or Attachments $0.05 per group

1 Gigabyte of Electronic Records $0.10 per gig

Digital Storage Media or Device, Container or Envelope, Postage and Delivery Charges: Actual cost

Customized Service Charge: Actual cost

Other form of reproduction (outside vendor): Actual cost

Requestor certification (for list of individuals only): I certify that any lists of individuals obtained through this request for public records will not be used for commercial purposes, per RCW 42.56.070(8).

Signature