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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GoVMUVJENT DATA PRACTICES ACT <br /> REQUESTER 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 dispute oractionis pending or additional sed to YOU for six months thereafter <br /> at-on <br /> unless a disp , <br /> you has been collected. <br /> B. You may be required to pay actual costs in maiming, <br /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: <br /> l <br /> Requester Name: J <br /> dress: c Z®-o (Dr !�•� City: <br /> Ad �'-n ��"'��'� <br /> zip: Fj cS sZ <br /> Home Phone: L-173- 7" <br /> Business: ?3 <br /> Description of Information Requested: <br /> t, <br /> Requester I.. s Signature: <br /> BELOW INFORMATION TOILLED IN BY DEPARTMENT ONLY <br /> r Handled By: �C�• <br /> Department: �� � �- <br /> aC` In person Mail Phone <br /> Request Type: <br /> Requested B Subject of Data C�!- Not Subject of Data <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: O- Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: x Total Due <br /> No. of Pages Rate per Page <br />