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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQIIEST <br /> MINNESOTA Ga DATA PR�CTICES 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 you for six montns 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 com�iling the copies o= ins"ormation <br /> requested. . ' <br /> i <br /> Date of Request: ���1'i ��� � "( (� I <br /> : �� . �� i <br /> �equester Name: � ` ` � � <br /> �, <br /> Address: C �� City: �� � <br /> ��C� C�f�s � �a�� U� , <br /> � <br /> Zi ��% �� � I <br /> P: � <br /> Home Phone� <br /> �� 1�1 � t7 � .. �� ( � Busines s: I <br /> Des cription of Inf ormation Ketsuested: ��G��i" �. <br /> o�w��S <br /> I, <br /> � ' ' - I!� <br /> Requester'. s Signatu�e: ' I� <br /> BELOW INFORMATI O BE FII�I,ED IN BY DEPARTMLNT ONLY i <br /> Handled By: i <br /> Department- ; <br /> Mai1 Phone � <br /> Request Types In person i <br /> g ested B Subjec� o= Data Not Subject of Data � <br /> � y= ` I <br /> Inf ormation Re�qa <br /> ested is Classified: �ublic Private <br /> Confidential Non-?ublic =rotected Non-Public � <br /> i <br /> Approved in Part � <br /> gequest is: Approved Denied _ _ .- <br /> Re.marks/Camments: ,C <br /> �'e.� . <br /> ture: j ii� ��n►i'�; ' ' ' ' `Qn� <br /> Authorized Signa .F�_ <br /> _ $ <br /> Fees:� X Total Due <br /> No. of Pages Rate per Page •• <br />