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ORONO ADMSNISTRATIVE OFFICES <br /> INFORMATION DISCI,OSIIRE KEQIIEST <br /> �SSNNESOTA GO DATA PR�CTICES ACT <br /> ' gEQIIESTER NOTE: . . <br /> A, Request Frequenc� - Private Data on individuals. After the <br /> have been supplied the data and informed of its meaning, <br /> data needanstube orsac�ion is pending or a d tional edatat-on <br /> unless a p . <br /> you has been collected. <br /> g, You may be required to pay actual costs in making, <br /> certifying and/or comailing the copies oi in=ormation <br /> requested. <br /> Date of Request: � t "� � � � �� `� <br /> Requester Nam.e- l,'L���i� l �11 ' " ,"� 's °'� �� � <br /> Addre s s. � �'i ` � � r; ll'J �4�����-1 -- City: G ��'� �'" 1�� <br /> � <br /> �._ � ;� � � <br /> Zip: .� �. _ _ <br /> .., ,� ,,. . <br /> ��� �- {r �� Cc �$ Business : ,.r ;: - :�: �st. "�. <br /> Home Phones � <br /> Descri.ption of Inf ormation Reuuested: �L�-� � - V1�C t C..�l �:� � �`� L �� �; <br /> .� , , -. . �_ <br /> ... <br /> _ , , . � �� '�;.� _ <br /> � . �'�• �iF�.r <br /> . ,:, <br /> � \ <br /> ';1 ,,t_�;4\ N <br /> „ <br /> . <br /> b1 <br /> i <br /> a.. <br /> � �.. �, t e'� <br /> (} • : � �(�. k� 1 ; >�> t ' ! c,'i� .r: :lL, _ . <br /> L..6`��.,,,I i V �i��� 1_��fJ� N�1 f�1,� }L1.�1���1 L'l�� t I �r <br /> �� Q /� <br /> ,� j , , ! ._., _.... <br /> Requester'. s Signature: <br /> i ' '; � .,•, � . <br /> BELOW INFORMATION TO BE� FII.LED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Typ <br /> e: In person Mai1 Phone <br /> ested B Subjec� of Data Not Subject of Data <br /> R� Y. ` <br /> Inf ormation Re�qu <br /> ested is Classified: ?ublic Private <br /> Confidential Non-?ublic :rotected Non-Public <br /> gequest is: Approved Denied Approved in Part <br /> Remarks/Ca�ments: <br /> Authorized Signature: <br /> _ $ <br /> Fees:� X Total Due <br /> No. of Pages Rate per Page .. <br />