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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GO DATA PRACTICES ACT <br /> REQUESTER NOTE - Private Data on individuals. After you <br /> A. Request Frequency <br /> the <br /> have been supplied the data <br /> and ouf foresixfmonthsits ethereafter <br /> data need not be disclosedyou <br /> or additional data -on <br /> unless a dispute or action is p <br /> you has been collected. <br /> be required to pay actual costs in making, <br /> B. You may the copies of information <br /> certifying and/or compiling <br /> requested. <br /> L <br /> Date of Requ <br /> est: ►� <br /> 0P it`) <br /> Requester Name: <br /> A.2� <br /> City: <br /> Address: <br /> � <br /> zip: SaL�Z> <br /> Z,Z <br /> Business: <br /> Home Phone: <br /> Description of Information Requested: <br /> ( 1tr �� 1Z�J ,L� <br /> vu,• L <br /> Requester`s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled BY: <br /> Department: <br /> In person <br /> Mail Phone. <br /> Request Type: — <br /> ct of Data <br /> Not Subject of Data <br /> Requested By: Subje <br /> Public _Private <br /> Information Requested is Classified: <br /> _Confidential <br /> Non-Public _=rotected Non-Public <br /> Denied Approved in Part <br /> Request is: Approved — <br /> Remarks/Cc ments: <br /> Authorized Signature: <br /> x Total Due <br /> Fees: es Rate per Page <br /> No. of Pag <br />