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ORONO ADMSNISTRATIVE OFFICES <br /> INFORMATION DISCI�OSIIRE REQIIEST <br /> MINNESOTA Ga DATA PRACTICES ACT <br /> REQIIESTER NOTE: <br /> A, Request Frequency - Private Data on individuals. Af ter you <br /> have been supplied the data and infornted of its meaning, the <br /> data need not be disclosed to you for six months 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 compiling the copies oi information <br /> requested. <br /> Date of Request: � - ��2� ��� <br /> Requester Name: �- NJC.�" t-t � L �E�tt�l�- . <br /> Addr e s s: j 3 S G �o`'l �� 5T Ci ty: �P�ip�f p�-i►� <br /> ziP: �5�35�1 <br /> � �� ��,1�E �St � c�t S <br /> Home Phone: - �° � s Business: <br /> S Sc� �c.� �n�� <br /> Description of Information �tequested: �� v <br /> ����� ��1u ���� <br /> �S <br /> Re�uester' s Signature: <br /> �,��'U-t�%C- <br /> BELOW INFORMATION TO BE FII,LED IN BY DEPART�iENT ONLY <br /> Department: <br /> Handled By: <br /> In erson Mai1 Phone <br /> Req�aest Type z P <br /> Re�uested By- Subject os Data Not Subject of Data <br /> Information Rer�uested is Classifie�: <br /> �ublic Private <br /> Confidential Non-�ublic -rotected Non-Public <br /> ge�uest is: Approved Denied Aoproved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees:� x $Total Due <br /> No, of Pages Rate per Page .. <br />