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ORONO AD:�i�IIS�R.AT=VE ��=�S ' <br /> �i�7'r ORMATIO:1 D=SGZOSURE REQIIEST _ <br /> • - ��gSp� � DATA PR�CTICES B.CT <br /> • ggQIIES��K NOTE: . - <br /> A. T�a�ZQS't Frequency - P=ivate Data on individuals. p��e= th� <br /> have been supp3.ied the aata and inforuzed of its II.e�ning� <br /> Qata �e�d not be discl.osed to you for six �onL:ns thereafter � <br /> . .tin 1gSS �� dispu�e or ac��on is �pending or additionz.l data -on <br /> you .has been. coll.ectec. � <br /> yQu aay be reauired to pay ��actual cos�s in �aking; <br /> B • zhe copi.es o� in=oraztzor_ <br /> certifying and/or co�ailing <br /> =eauested. • <br /> Date o� Recruest: 5 - 2' q - O � � <br /> gequester Name: c�l��``�E S v�, ��'�-}�✓5oN . <br /> �dress- � 300 �,c)/}-7��� T�W/� ��� <br /> City: �`�/-���� �L I�ll✓ <br /> . Zip: �'S35�y . <br /> Hame Phane: �f S2- �/ 7 S - 31 S j Business: <br /> ,� �i rs �- <br /> Descr�pt=.on of Information Requested:. �UI�D/NG p 1� <br /> c s �o� a a o ci� �Pr-�� a s �i-+ �P���v � � <br /> N `� VJ� /��' � . . <br /> � Retraester'. s Si.gnature: <br /> BEI�OW INFORt�iATION _0.- E FI <br /> I BY DEPAR�N� 02�LY <br /> 6� 2-- Haudled Fy= �� ' <br /> D ep ar�e.�t= <br /> Mail. Phone <br /> ge�uest Type- �_Zn peYsan — -- <br /> Subjec� o= Data PC Not Subject or" Data <br /> g�ues�eci By= ` <br /> �fo�atj.on Requested is Classifi.ed: <br /> D� �u'r�lic _Private <br /> �;a�-?ublic _=rotected Nan-Public <br /> Con=�dential - <br /> Denied � Aoproved in_Par� <br /> g�cruest is= OL Aooroved — � ' . <br /> Re�arks/Coarments- . <br /> p,II.�ori.zed Signat�xe: . <br /> = S <br /> Fees:• X Tota1 DLe ., <br /> Ko. of Pages Rate per Fage <br />