Laserfiche WebLink
3 <br />REQUEST RELEASE DATE <br />REQUESTING AGENCY <br />AGENCY ADDRESS <br />4. INDIVIDUAL REQUESTING <br />5. INDIVIDUAL ADDRESS <br />FILE ADDRESS <br />PUBLIC RECORD RELEASE REQUEST <br />�tw <br />ITEM REQUESTED DATE PURPOSE OF REQUEST <br />*ASTERIr�/ILME W TED FOR PHOTOCOPYINGSIGNATURE OF REQUESTING PARTY ��DATE d • l �i g <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL cli"i DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND ONITORING OF THE RECORDS. <br />4/81 <br />