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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GoVMUR4ENT 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 yending or additional ou for six months 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: <br /> � �c_ _ <br /> Address: <br /> O <br /> City: �° i �/`/ �� •��v <br /> zip: ��;Ti7 <br /> Home Phone: <br /> 9 ©?3 Business : 93IZ- <br /> Cl Z,,4,-Z! <br /> Description of Information Requested: <br /> C✓=ff., 57. e6:_ <br /> Requester' s Signature: <br /> : <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: <br /> In person Mail Phone <br /> Requested B Subject of Data Not Subject of Data <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: Page Total Due <br /> No, of Pages Rate per g <br />