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ORONO ADMI]�IISTRATIVE OFFICES <br /> INFORMATION DISCLOSDRE REQIIEST <br /> MINNESOTA GOVER]!TI�NT 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 you for six months thereafter <br /> unless a dispute or action is pending or additional data on <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: ,j - ��' - i .2 <br /> Requester Name: 3� .� ,�'�i�t-�h�1 ����� c3 �.� ,�c2�-f �/� <br /> Address: �5�.�� %�c3i�,,,� s' ��%� .-� J� �i r.� � City: ��°%� .,�� <br /> Zip: .�� � i � _ <br /> Home Phone: y �/ -�.T C� �; Business: ��,;., � <br /> Description of Information Requested: �i?-,� �., ,�� � �u �,�f. •; <br /> �:, �� �•t <br /> .�, .�,, �dE�,- � ,� �,��� � <br /> �, <br /> , _ <br /> Requester' s Signature: � ,�_ <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: Q f Z Handled By: <br /> Request Type: In per,�on Mail Phone <br /> Requested By: Subject c�f Data Not Subject of Data <br /> Information Requested is Cla:ssified: �Public Private <br /> Confidential Non-l?ublic Protected Non-Public <br /> Request is: �Approved Denied Approved in Part <br /> Remarks/Ca�ments: <br /> � <br /> Authorized Signature: <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due � <br />