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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE PRACTICES REQUEST <br /> ACT <br /> MINNESOTA GOVERNMENT <br /> REQ17ESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After the <br /> have been nasupplied isclosed to youhe data and f foresixfits monthsethereafter <br /> data need not b <br /> unless -a dispute or action is pending or additional data -on <br /> you .has- been collected. <br /> You may be required to 'pay actual costs in making, <br /> B. . the copies of information <br /> certifying and/or compiling <br /> requested. <br /> Date of Request: <br /> Requester Name: J/ <br /> Address: <br /> .� S City: <br /> . Zip: �jCJ�(,�o <br /> Business: <br /> c�S1 /(o yS- (0330 <br /> Home Phone: <br /> Description of Information Requested:. <br /> Requester's Signature: <br /> BELOW INFORMATION <br /> .14 IDLED IN BY DEPARTMENT ONLY <br /> 6�r) Handled. By. <br /> Department: <br /> Mail Phone <br /> Request Type: _�ln Person — — <br /> Requested By: _Subject of Data <br /> cL Nvt Subject of Data <br /> ub Ii c Private <br /> _,_ <br /> T—nfoffiation Requested is Classified: _�P <br /> protected Non-Public <br /> Confidential <br /> Non-?ublic <br /> Approved Denied Approved in Part <br /> Request is: __ — <br /> Remarks/Comments: <br /> ------------------- <br /> Authorized Signature: <br /> = S <br /> Fees:- x Total Due <br /> No. of Pages Rate per Page <br />