Ill. Admin. Code tit. 2, § 200.APPENDIX A
| 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 | ||