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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSIIRE REQIIEST <br /> MINNESOTA GO�i�NT 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 /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: .%�� / `�� <br /> Requester Name: ���((,�{'l� ���V�CEI� <br /> Address: �J�� ��P✓IC�� ��- City: ��� �t� <br /> z�P: �� - ���--�' ����� <br /> Home Phone: �� �{(� 7GnX Business: <br /> Description of Information Requested: <br /> ��l s� l�r�t:��,/ i Gllit/� �c��) C�1- ��C�; SGlc��'•�l�V� �Yi d� <br /> Reqnester' s Signature: �' -l 1���-C �h"' \ � <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMF:NT ONLY <br /> Department: Qt 2 Handled By: <br /> Request Type: D� 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�ents: <br /> Authorized Signature: U�-� <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due <br />