DATA REQUEST FORM

Name*:

Title:

Department/Office: Status*: Choose one. Administrator Faculty Staff Other

Phone*: Fax: E-mail*:

Request (e.g., Student headcount by ethnicity, Fall 2005)*

How will requested data be used?

What/who will be the intended audience for this data?

When do you need the data?* Month Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec /Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Year 2006 2007 2008 2009 ( *Required Fields)

In what format do you wish to have the data? Choose a format. ASCII HTML Excel Word Other Other format:

Please allow 10 working days for your request to be processed.