Member Information Request

Policy 300-040: Member Request for Information

NOTE: No information concerning CCEC, its members, personnel, trustees, agents, employees or operations shall be made available (except routine information) unless the requesting member completely fills out and executes this information form.

MEMBER REQUESTING INFORMATION

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

TELEPHONE NUMBER

INFORMATION REQUEST DETAILS

LIST MEMBER(S) THIS INFORMATION WILL BE SHARED WITH INCLUDING NAME, ADDRESS, TELEPHONE NUMBER, & EMAIL

STATE SPECIFICALLY WHAT INFORMATION IS BEING REQUESTED

STATE SPECIFICALLY WHY YOU WANT SUCH INFORMATION AND TO WHAT PURPOSE YOU WILL USE IT

IF YOU ARE REPRESENTED BY AN ATTORNEY IN THIS REQUEST, PLEASE STATE SUCH ATTORNEY’S NAME, BUSINESS ADDRESS, TELEPHONE NUMBER, & EMAIL

MEMBER REQUEST CONFIRMATION

I UNDERSTAND THAT BY EXECUTING THIS REQUEST FOR INFORMATION, I AGREE: (1) TO ABIDE BY CCEC’S POLICY AS TO DISCLOSURE OF CCEC’S BOOKS AND RECORDS AS CONTAINED IN ATTACHED POLICY. (2) NOT TO USE SUCH INFORMATION FOR ANY PURPOSES OTHER THAN THOSE SPECIFIED HEREIN,

I UNDERSTAND THAT BY EXECUTING THIS REQUEST FOR INFORMATION, I AGREE:

(1) TO ABIDE BY CCEC’S POLICY AS TO DISCLOSURE OF CCEC’S BOOKS AND RECORDS AS CONTAINED IN ATTACHED POLICY.

(2) NOT TO USE SUCH INFORMATION FOR ANY PURPOSES OTHER THAN THOSE SPECIFIED HEREIN,

MEMBER SIGNATURE

DATE

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Member Information Request