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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GoVMUU4ENT 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 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 /> ZLI <br /> Requester Name: <br /> 7city: <br /> Ql� <br /> Address: 2 <br /> zip: 3s� <br /> 2 Business: <br /> Home Phone: 7 <br /> Description of Information Requested: <br /> Requester`. s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> D ep artme-nt: <br /> Request Type= person erson Mail Phone. <br /> Requested B Subject of Data Not Subject of Data <br /> � y: <br /> Information Requested is Classified: Public _Private <br /> Confidential Non-public -rotected Nan-Public <br /> Request is: <br /> Approved Denied Approved in Part <br /> Remarks/comments: <br /> Authorized Signature: <br /> Fees: x Total Due <br /> No. of Pages Rate per Page <br />