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,� 3 ��s. <br /> ORONO ADM.INISTRATIVE OFFSCES � <br /> INFORMATION DISCLOSIIRE REQIIEST / <br /> MINNESOTA Ga DATA PR�CTICES ACT <br /> ' REQIIESTER NOTE: <br /> A. Request Frequency - Private Data on individual.s. After you <br /> have been supplied the data and informed of its meaning, the <br /> data need not be disclosed to you for six montns thereafter <br /> unless a dispute or action is pending or additional data -on <br /> you has been collected. <br /> g. You may be reguired to pay actual costs in making, <br /> certifying and/or compiling the copies oi information <br /> requested. ' <br /> � <br /> Date of Request: � � � '' <br /> Requester Name: ����' <br /> Address: �,3�C7 G- � City: �G[\�*� i <br /> i <br /> ziP: �'�J3�� j <br /> gome Phone: ���''�"_ 3 Business: <br /> i <br /> Description of Information Re�uested: <br /> � � <br /> �..5 -u2 .L'`�I�-�c <br /> Requester'. s Signature: <br /> BELOW INFORMATION ED IN BY DEPART�NT ONLY ' <br /> �t2 $analea By: .c� <br /> Department- <br /> Request Type: <br /> p� In person Mai1 Phone <br /> g�qiaested By' Subjec� of Data � Not Subject of Data � <br /> . � ; <br /> Information Re�qnested is Classified: <br /> � �ublic Private I <br /> Confidential Non-�ublic �rotected Non-Public <br /> ge�uest is: _�Approved Denied Approved in Part <br /> Remarks/Com�ments: <br /> Authorized Signature: <br /> _ $ <br /> Fees:- x Total Due <br /> No. of Pages Rate per Page �- <br />