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ORONO ADMSNISTRATIVE OFFICES <br /> INFORMATION DISCLOSIIFZE REQIIEST <br /> NiINNESOTA Ga DATA PRACTICES ACT <br /> ° gEQIIESTER 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 y nding or add ti nal edatat�on <br /> unless a dispute or ac�ion 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 oi information <br /> requested. <br /> Date of Request: � ���� � / <br /> �{� � / � <br /> Requester Name= I\ � �/ ��-� `�C �ls��n ` <br /> � j�� :; > >� City: � �ic �?<�"Tc�-- <br /> Address: � J,�'u �'/1-�� � � � � ����` <br /> z�P: s� ��� � y 3 <br /> '�� 3 .-�� '/ �_ � ` _7C) <br /> Home Phone: L�-�'X�'��- Business : T � � � �"�`- <br /> Description of Information Re�queste3: <br /> � �;Y � � �' `- '�/,� � ��f' S� ��_ , � C� �Y�/- �Q.S <br /> �` �. � � / <br /> C���� .''t,�`f.'r �f6� /^� ��i-t� �"�'1 f�'C( �ri �7/S��G-�- <br /> �n--�r:R��,( <br /> y � ,� - '�`���1 -� , .�, ��y��:S <br /> L �. <br /> Requester' s Signature: ��'� � � <br /> BELOW INFORMATION TO BE FII�LED IN BY DEPART�?NT ONLY <br /> Department: <br /> Ha.ndled By: <br /> Request Types <br /> In person MaiZ Phone <br /> ge�quested By- Subjec� o= Data Not Subject of Data <br /> Information Requ <br /> ested is Classified: ?ublic Private <br /> Confidential Non-?ublic =rotected Non-Public <br /> ge�uest is: APP <br /> roved Denied Approved in Part <br /> Re�arks/Co�ents: <br /> � <br /> Authorized Signature: <br /> C��i���- �-����,� - <br /> _ $ <br /> Fees: x Total Due <br /> No, of Pages Rate per Page .. <br />