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ORONO ADMSNISZ'RATIVE OFF=�S � <br /> i <br /> 1�FORMATION DISCLOnS�UREPR 4�I�S ACT ' <br /> MSNNESOTA Ga <br /> ' gEQIIESTEFt 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 ada tionaledatat-on <br /> unless a dispute or action is p <br /> you .has been coll.ectea. <br /> B, you may be reauired to P�y thet copies Sor inform ti°n <br /> certifying and/or comDiling <br /> requested. � <br /> Date vf Request: J <br /> ' � � � ?it,i� <br /> Requester Name= r - <br /> ' � City: i2��.� <br /> Address: � <br /> ziP: �i53 / � <br /> gome Phone= <br /> �7�� C�7�U Business: 'y �i ����G/ <br /> Description of Information Reuueste3: � <br /> . �; :, � °�C . <br /> � � <br /> � ; _ G�C.G <br /> � - � <br /> L' <br /> Reuues e . s Signatur . <br /> BgyOW I27gOR��TION TO BE F I�I�ED IN BY DEPARTMENT ONLY <br /> ��2 s�.ai�a By: ��. <br /> Department= <br /> Mail Phone <br /> gequest Type= � in pe=son — <br /> Subjec= of Data � Not Subject of Data <br /> gequested By= _ ` <br /> Information Re�quested is Classified: <br /> �_?ublic Private <br /> Considential <br /> Non-?ubZ�� =rotected Non-Public <br /> �_Approved Denied P_pproved in_Part <br /> Request is: — <br /> Remarks/Comments: <br /> ' 1���/1^^--- <br /> Authorizea Signat�re: <br /> = S <br /> Fees:• x Total Due .. <br /> No. of Pages Rate per Page <br />