RICHARD BLAND COLLEGE

OF

THE COLLEGE OF WILLIAM AND MARY

FREEDOM OF INFORMATION ACT REQUEST

Name of Person Requesting Information: ____________________________

Address: ____________________________

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Date of Request: ____________________________

Information Requesting: ____________________________

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Certification:

I hereby certify that I am a citizen of the State of Virginia as determined by state law or represent a news organization operating in Virginia.

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Signature of Person Requesting Information Date of Request

College Response: __________________________

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Date of Response: __________________________

Amount Charged for Requested Information: __________________________

Receipt Number: __________________________

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Signature of Human Resource Director/ Date of Response

Human Resource Personnel