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ORONO ADMINISTRATIVE OFFIC$S <br /> INFORMATION DISCLOSDRE REQIIEST <br /> MINNBSOTA GOVERAIl�NT DATA PRACTICSS ACT <br /> RBQDESTER 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: �� - 1'��-� <br /> Reqnester Name: ' <br /> Address: _�/h� /�/ ��ior �r�✓ CitY= �ra» o <br /> Zip: SS`39/ <br /> Ho�e Phone: .t/7/- 9S2v Business: <br /> Description of Information Requested: �is�orU o� �i�o��,�-.,. <br /> Reqnester's Signature: <br /> BELOW I1QF'ORMATION TO BE FII,LED IN BY DBPARTIKB'NT ONLY ' <br /> Department: Handled By: <br /> Request Type: In person Mail Phone <br /> Reqnested By: Subject of Data Not Subject of Data , <br /> Information Reqnested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/C�ents: <br /> Authoriaed Signature: <br /> Fees: x = $ <br /> No. of Pages Rate per Page Tota Due � <br />