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ORONO ADMINISTRIITIVE OFFICES <br /> INFORMATION DISCLOSIIRE RE4DEST <br /> MINNESOTA Ga DATA PRACTICES ACT <br /> REQIIESTER NOTE: <br /> A, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, the <br /> data nea distute orsaction is pending or add tional edatat�on <br /> unless P . <br /> you has been collected. <br /> g, yQu may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies oz inrormation <br /> requested. <br /> Date of Request: <br /> � �� <br /> ' ����� /� �/' <br /> Requester Name: ,., <br /> ' � � � _ <br /> � � �Z - City: <2�: <br /> Address: <br /> Zip: s'�� y � <br /> Home Phone: /����"/�5�C��� Business : <br /> Description of Information Requested: <br /> /'�� G" �� <br /> ' s Si ature: �'� �'��� <br /> Re�uester � <br /> BELOW INFORMATION TO BE FI ED IN BY DEPARTMENT ONLY <br /> !�£� Handled By: CI — <br /> Department s �� <br /> Request Typ <br /> e: � In person Mai1 Phone <br /> R ested B Subject oz Data � Not Subject of Data <br /> equ y: <br /> ublic P <br /> Information Requeste� is Classified: � � Privat_ <br /> Confidential Non-?ublic =rotected Non-Public <br /> Request is: D�' Approved <br /> Denied Approved in Part <br /> Rp�arks/Comments: <br /> Authorized Sigaature: <br /> � �-�`-`'`�`'--� <br /> _ $ <br /> Fees: X Total Due <br /> No. of Pages Rate per Page .. <br />