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ORONO ADMSNISTRATSV� OFFI�S <br /> =NFORM�ITION DISCI�OSIIRE R�4�ST <br /> MSNNESOTA C� DAT� PR.ACTICES ACT <br /> �Q�S�gR NOTE: ' �- on individua�s. AitAr y°u <br /> A, Request Frecuency - Private Da�.a <br /> the <br /> have be�n suppl.ied the data ana uf fQ e`31X=�on�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 coZlected. zCtual costs in making, <br /> vou Inay be reau'-red to p�Y �^ o= inrormation <br /> B. certifying and/or compiling �.l.e copies <br /> requested. <br /> ��. �. <br /> � �_ <br /> Date of Re�eSt: � � / , .. <br /> '� � � , �t ,�_ �%�:^C<�� <br /> Req�ester N�e= ` � / <br /> , <br /> � -=� � /�cr / a�F �i�i�CitY: %'o,� ,, G <br /> � l �� ���" � �- <br /> A,ddress- - - _ / <br /> Zip: , - < <,- <br /> u < -- ,�<: ,, _� <br /> Hame Phone: y_ J��� - c�� �. _, ,_1 <br /> Business : �� "� <br /> r-r'� - ('� �/�/ _.. - <br /> Description of Znformation Reuueste�: <br /> Re�uester' s Signature= <br /> BELOW INFORMATION TO BE F�� I� BY DEPARTI�NT ONLY <br /> Handle�d BY= <br /> Depart��t= <br /> Mai� �hone <br /> Request Type- —In persan — <br /> Not Su.i�jec� of Data <br /> Subjec� or" Data — <br /> Requested By= , <br /> ��Zyc pTyvate <br /> Tnfo�ation Requested is Classifie�: <br /> �ub1;c =r°teC+�d Nan-Public <br /> Consicential Nor�-- <br /> g�quest is: Approved <br /> Denied Approved in Part <br /> Re�r3�cs/Ca�me.nts: <br /> Aut�iorize� Signatnre: <br /> _ $ <br /> X Total Due <br /> Feess No. of Pages Rate per Page .. <br />