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ORONO ADMSNIS�R.ATIVE OFFICES <br /> I�FORMATION DISCLOSURE REQIIEST <br /> MINNESOT� Ga DATA PR�CTSCES ACT <br /> ' gEQUESTER NOTEs <br /> A, Request Frequency - Private Data on individuals. Af ter you <br /> have been supplied the data anci informed of its meaning, <br /> the <br /> data need not be disclosed to Yeriding or a ditional edatat-on <br /> u n l e s s a d i s pute or ac..ion is p <br /> you has been collected. <br /> g. You may be required to pay actual costs in making, <br /> certifying and/or corr�piling the copies oi iniormation <br /> requested. <br /> Date of Request: - � � <br /> Requester Name- ._ <br /> City: _ <br /> Address: <br /> Zip: � <br /> HQme Phone: <br /> Business= <br /> Description of Information Ftequested: <br /> Requester'. s Signature: - <br /> BELOW INFORMATION TO BE FIT�.LED IN BY DEPARTMLNT ONLY <br /> ' > � Handled Bv: 1 . <br /> Depart�ent: �; -- �-_ <br /> � In erson Mai1 Phone <br /> Reqnest Type: p <br /> Subjec� or Data ,�c� Not Subject of Data <br /> gequested By: ` <br /> Inf ormation Reqa <br /> ested is Classified: �_�ublic Private <br /> Coniidential <br /> Norz-?ublic :rotected Nan-Public <br /> gequest is: \' Approved Denied Approved in Part <br /> Remarks/Car�ents: <br /> Authorized Signature: <br /> ' ( C�_ ; ., - <br /> , _ $ <br /> Fees:- X Total Due <br /> No. of Pages Rate per Page <br />