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� 4�� �;���� <br /> ���� 1 ��7 <br /> ORONO ADMSNSS�RATNE �E'F=�ES - <br /> INgORMATION DISCLOSIIRE RE4.IIEST <br /> . MS�NESaT�, G� DATA PR�CTICES B.CT <br /> • ggQUESTER NOTE: . <br /> A. gecruest Frequency - Private Data oa individuals. �teT the <br /> have been suppleeQi�losed to youf foresixfmon�:nsethereafter � <br /> data need not b � . eBding or adaitional data -on <br /> �unless `a dispute or ac,.zon is p <br /> you .has been coI.l.ected. <br /> g. you may be reauired to pay actual cos�s in making� <br /> certifying and%or om�iling the copies o= informati°n <br /> requested. • <br /> Date of Request: <br /> � � �j�b <br /> Requester Name. ���/�/o � � <br /> ��� �'�7'd'� '�1�� City: %n � Z��'/�'_�_ <br /> p�ddress: � <br /> Z ip= ��� � � <br /> Phone: � - 2 � � Busines s: � ���-5� ! 2 <br /> Home � � <br /> Description of Inf°�a�'on Re�ested: <br /> , ` t�, �- � <br /> �_ � <br /> �-� ��-C��1 �`� �' - <br /> 1 <br /> � �� <br /> Retruester`. s Si.gnature: <br /> BgyOW INgOR�`�1ATION TO FITsI�El7 IN BY DEPAR�� O�Y <br /> � <br /> ��� _ Handled BY= <br /> Depart�ent= <br /> Mail ?hone <br /> Request TypeS In persan . — . <br /> g�uested By= — <br /> Subjec:. of Data Not Su�ject os Data <br /> ?u.nlic Private <br /> Tn�Formation Reqaested is Classified= — <br /> Nan-?ublic -rotecte� Non-Public <br /> Con=idential — <br /> _�Aporoved Denied Anproved in_Part <br /> gequest is: -- <br /> Remarks/Coasments: <br /> Anthorize3 Signature: <br /> _ $ <br /> Fees:• X Tota3 DLe ._ <br /> No. of Pages Rate per Page <br />