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ORONO ADMINISTRATIVE OFFICBS <br /> INFORMATION DISCLOSDRE REQIIEST <br /> 1KINN$SOTA GOVBRI�II�NT DATA PRACTICSS ACT <br /> REQIISSTEIt 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 Reqnest: Q �� "1 � <br /> Reqnester Name: ��yr�P� ,L.�16 �e,�.- <br /> Address: al�"' ���vtl� ��l70� City: <br /> Zip: ��1� <br /> H�e Phone: y7S '��� � Business: <br /> Description of Information R ested: <br /> � b�� �r �l s � � lu�� � <br /> b V1� r���c�. <br /> Reqnester's Signature: <br /> BEIAW INFORMATION BS FILLED IN BY DEPARTl�N'P ONLY <br /> Department: ��Z Handled Bp: � <br /> Request Type: In person �Mail Phone <br /> Requested By: _�Subject of Data Not Subject of Data , <br /> Information Reqnested is Classified: �Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Reqnest is: �Approved Denied Approved in Part <br /> Remarks/Ca�ments: �i L �-r� p w N E"� <br /> Authoriaed Signatnre: <br /> Fees: x � _ $ <br /> No. of Pages Rate per Page Total Due • <br />