CCTV Data Request Form

Details of Applicant

Title*

First name*

Surname*

Telephone number*

Postal or e-mail address*

Date of incident:*

Time:*

Location:*

Description of incident:

We will NOT request any statement from Principal (Maulana Faruk) or the staff of Madrasah. we understand they remain neutral. *

Signed:*

Date:*

98 Revidge Road, Blackburn,
United Kingdom, BB2 6JQ