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ORONO ADMSN2STR.ATIVE OFFSCES � <br /> =3�TE'ORMATION DISCLOSIIRE REQUEST �s <br /> � MSNPTESOTA Ga DATA PR�CTICES gCT <br /> ' gEQIIESTER NOTE: � <br /> A, gecruest Frequency - Private Data on individuals. �te=' Y°u <br /> have been supolied the data and informed of its meaning, the <br /> data ueed not be discZosed to yending or ada t onaledatat-on <br /> unless `a dispute or ac�ion is p <br /> you .has been col.Iected. <br /> g, you may be reauired to pay actual cos�s in making, <br /> certif ying and%or compiling the copies o= inf orn.ation <br /> requested. - <br /> Date of Request: <br /> � , , �� -<�f.`C% C� <br /> ` �C-J�-�2 i C �/ . �'� �n�C%-�i � L Z�; <br /> Req�ester Name: � : <br /> Z z� � , ��.,J ',� czty: �����1 G C�� � <br /> Ac3dress- � ��S I'" � (�`"� �✓ `� - <br /> � Zip: � � � 5 C' � � -7� ._ J�j' CJc� <br /> ` � zJJ Business: 7�� ' J <br /> gome Phone: �/ �' Y <br /> Description of Informa�-on R�ested: <br /> �C,4,,i J� —� I'Z S/'�� 2 l ��%�c��l . <br /> � <br /> � <br /> Requester'. s Signature: <br /> BgyaW SLTFORMATION TO BE FII.LED IN BY DEPART�H� O�Y <br /> � .z $�aiea sy_ ��:�l�d��— <br /> Depart�ent= <br /> Mai1 Phone <br /> Request Type� �_In person . — — <br /> gequested $y= <br /> Subjec� o= Data _ `► Not Su°7ec� of Data <br /> Tnformation Re�u <br /> ested is Classified: �..��ZzC Pr1V��e <br /> Conf idential <br /> Non-?ubZi� =rotected Non-Public <br /> � Aporoved Denied P_pproved in_Part <br /> gequest is: — <br /> Remarks/Cau�.ents. <br /> - . �� j�-���t,�'�, <br /> Anthorized Signat�re: � <br /> G., !�� _ $ �. '� - <br /> Fees:• .� X Total Due ., <br /> No. of Pages Rate per Page <br />