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OR0210 ADMINISTRATNE OFFI�S <br /> rNFORMATION DISCLOSDRE REQU�ST <br /> MINNESOTA Ga DATA PRACTICES ACT <br /> ggQUESTER N��- � - p� vate Data on individuals. Af ter you <br /> A, Request Frecruenc� i <br /> the <br /> have been supplied the data and Quf fo eSiX=mon�sethereafter <br /> data need not be disclosed to Y � <br /> ute or action is pending or additional data -on <br /> unless a disp . <br /> you has been col.Iected. <br /> B. you �ay be required to paY <br /> actual costs in makin9. <br /> certif ying ar_d/or ���Pi ling <br /> t'r.e copies oz in=ormat�on <br /> requested. � <br /> Date of Request: <br /> ��� _ a L.( - �� � <br /> ' - _3_ �j l� js� <br /> Reqnester N�e= �- � <br /> Address: <br /> �U � `-( �' �� �� �.. ` j�� �f�c� • City: �; /:G��' c_i — <br /> z�p: �l �� - � � =� J <br /> H�,e Phone: Ll l � -- �. "3 � �7 Business: <br /> Description of Informa-t�on Re�u'este�.: <br /> � ll,��� � �� I �- <br /> � �v,�� ..• a� <br /> Reqaester' s Signature= <br /> BgyOW IIrTFORMATION TO BE FII�.LE� IN BY DEPARTM�NT ONLY <br /> _ ��. � Handled By: �` ` v' <br /> Departsi.e-nt• <br /> Request Type= � In persan <br /> Mai1 Phone <br /> Subje�� o= Data <br /> �_Not Sub j ect of Data <br /> gecrueste3 BY= — <br /> Tnformation Requeste� is Classified: oC <br /> �u�lic _P'-'i`rate <br /> Non-�ublic =rotected Non-PuDlic <br /> Coniideztial — <br /> gequest is: Aporove� <br /> Denied Approved in Part <br /> Rem.ar�s/Car��ts: <br /> Authon-Z� S1gaature= <br /> _ $ <br /> x Total Due <br /> Fe�s� No. of Pages Rate per Page �- <br />