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ORONO ADMINISTRATNE OFFSCES <br /> INFORMATION DSSCLOSIIRE RZ'S2�ST <br /> I4INNESOTA Ga DATA PR�CTICES ACT <br /> ' gF:QIIEST�R 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 you for six months thereafter <br /> unless a dispute or action is pendinq or additional data -on <br /> you has been collectec. <br /> g, You may be requirec to pay actual costs in making, <br /> certif ying and/or compiling the copies o� information <br /> requested. � � <br /> Date of Request: C���w'� `'�'��'��•� � `C��� <br /> Requester Name: �t�t �v�������1 ���%�0 61 <br /> r i� ����,� city: ��I I-�1�'l�'�1�%��'_� <br /> Ac�.dS2$$: � `� r� � <br /> zip: ���-�� ��1 "����� <br /> Ham.e Phone x <br /> ���7_-G�?�� � ���Q � Business= ��� <br /> Description of Information Requeste3: <br /> -� '����� �f��YI,tU <br /> ' �� ��;�� �'titi ��h u�� ���;'����?1 ti��1 ti '� "� i. <br /> � /n,��. („�i ,��1 � �/�� �/���,� <br /> Requester'. s Signature: (, <br /> BEI�OW INFO�TION TO BE FII�.LED IN BY DEPART�.'NT ONI'Y <br /> I�C 7 Handled By: <br /> Department= — <br /> Request Type= � In Pe=son <br /> Mai1. Phone <br /> gequested By= _ <br /> Sub j ec� of Data � Not Sub j ect of Data <br /> Information Requ <br /> ested is Classified: l� �ublic _Private <br /> Confidential Non-�ublic =rotected Non-Public <br /> v A�oroved Denied P_pproved in_Part <br /> gequest is: _ <br /> Remarks/Ca�ments: <br /> Authorized Signatnre: <br /> _ $ <br /> Fees:� eS X Rate per Page Total Due <br /> No. of Pag <br />