Directory Information Request Form printable pdf download

DIRECTORY INFORMATION REQUEST FORM

Date of Request: ________________________ Name of Requestor: ___________________________________

Company/Organization: _______________________________________________________________________

Phone Number(s): _____________________________ Email Address: _________________________________

Mailing Address: _____________________________________________________________________________

Please indicate the directory information you request:

 Student name

 Student grade

 Student address

 Contact phone number

 Contact email address

 School name

 Primary language spoken

 Other______________________

 Other _____________________

Target population: ______________________________________________________________________________

Purpose of request: ______________________________________________________________________________

_______________________________________________________________________________________________

Please indicate whether you meet any of the following criteria (see 3231SP for more information):

 I am engaged in a cooperative activity that directly serves or provides operational support for a school/program.

 My purpose is to inform students/parents of educational, training, or career opportunities that have significant merit

and will be of interest to a significant portion of the target population.

 Other ____________________________________________________________________________________

____________________________________________________________________________________________

The undersigned declares as follows:

I have requested the above-described directory information.

I hearby declare that this directory information shall not be used for commercial purposes.

•

RCW 42.56.070(9) prohibits any public agency from providing access to lists of individuals requested for

commercial purposes. Commercial Purposes is defined in AGO 1998 No. 2.

•

A requestor who signs a declaration promising not to use a list of individuals for commercial purposes, but who

violates this declaration may be charged with the crime of false swearing. WAC 44-14-06002(6).

•

Disclosure of District lists of individuals to a third party for commercial purposes is prohibited.

Requestor’s Signature: _________________________________ Date: ________________________

For internal use only

PRO Recommendation:  Approve  Disapprove Referred by: _________________________ Date: ____________

Request is:  Granted  Rejected Final decision by: _________________________________ Date: ______________

Directory Information Request Form