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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMENT 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, <br /> the <br /> data need not be disclosed to you for six months ending or additional edatat�on <br /> er <br /> unless a dispute or action is p <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 /> Requester Name: -J 0.1,--0.4 <br /> Address: o� �,\%/ �: tit, <br /> City: <br /> 3S q(01?, ( <br /> Zip: ,�------------------.,� <br /> 44q, _ Business: <br /> Home Phone: � <br /> Description o/f� Information Requested: <br /> /u-( C-1 WA - r <br /> Requester' s Signature: <br /> BELOW INFORMATION TO = LLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> person Type: <br /> In Mail Phone <br /> t <br /> Subjecof Data Not Subject of Data <br /> Requested By: '- <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> PP <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 />