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ORONO ADMINISTRATIVE OFFICBS <br /> INFORMATION DISCLOSDRE REQIIEST <br /> MINNESOTA GOVERNMENT 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 need not be disclosed to you for six months thereafter <br /> unless a dispute or action is pending or additional data on <br /> you has been collected. <br /> B. You may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies of information <br /> requested. <br /> Date of Request: <br /> �� � �� <br /> Requester Name: ��� �� ��� � ��� <br /> �� � �((� Cit � � I �i L� �; � �.i� <br /> Address: � � ��'� ��� �—' - y' � �- <br /> z��: 0 ��� � � <br /> ����� � ", � � �� Business: � � �- � �'� ��� v��� �� � <br /> Home Phone: , <br /> Description• of Information Requested: <br /> ��� �%1-��� Y^Y\��`s� .a ����,,"� Q (�l,i� �/\� I lY� ���(� � <br /> _ ,� ��� � Q�'MiJ � � <br /> Requester' s Signature: <br /> ���i ('� i �. 1�.J � <br /> BELOW INFORMATION TO BE FII.LED IN BY DEPARTMENT ONLY <br /> Department: Q �Z Handled By: c..Y�� <br /> Request Type: _ � In person Mail Phone <br /> Requested By: Subject of Data �- Not Subject of Data <br /> Information Requested is Classified: �_Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Co�aents: <br /> Authorized Signature: <br /> Fees: x — $ <br /> No. of Pages Rate per Page Total Due <br />