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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE PR CISCSS ACT• MINNESOTA GO <br /> VERNMENT REQtfESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After youhave been supplied the data and informed <br /> f o ediofx mitr.' meaning, the <br /> .data need not be disclosed to yending or additional data -on <br /> onless `a dispute or action is -p <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 /> Al <br /> Requester Name: _ Iii:l. �`` <br /> CP � % City:Address: � -%�'`'�' <br /> I <br /> Zip: ��a c��(p� lj 1p � - <br /> Home Phone: <br /> 'Z_c�7 _ ` 6/ �_ s Business: <br /> Description of Info kation Requested: <br /> A <br /> Requester' s Signature: <br /> BELOW INFORMp,TION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: In Person <br /> Mail Phone <br /> Requested By: <br /> Subject. of Data Not Subject of Data <br /> Public Private_ <br /> Information Requested is Classified: <br /> -Public Protected Non-Public <br /> Confidential Non � <br /> Approved Denied <br /> Approved in Part <br /> Bequest is: <br /> Remarks/Comments: <br /> . • L.--)'',40. 1r <br /> Authorized Signature: <br /> Pees: x Total Due <br /> No. of Pages Rate per Page <br />