----------------------------------------------------------------------------------------------------- Name of person making request (please print) | |||
------------------------------------------ Address | ------------------------------------------ City | ||
----------------------------------------------------------------------------------------------------- Telephone Number | |||
----------------------------------------------------------------------------------------------------- If inspection is being made on behalf of another individual or group, print the name of the second party. | |||
Full description of records to be inspected: | |||
------------------------------------------ Date | ------------------------------------------ Signature of person making request |
Ill. Admin. Code tit. 2, pt. 200, subpt. C, app A