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ORONO ADMSNISZ�tATNE OFFSCES <br /> 23`TFORMATION DISCLO�S�UREPR 4�I�S �CT <br /> � �1SNZTESOT� Ga <br /> • �LEQIIEST�R NOTE- . <br /> A. geQuest Freque:�cy - Private Data on individuals. �te= the <br /> have been supplied the aata and ouf fQ esixf�on�se�ereafter � <br /> data ueed nat be disclosed to y <br /> �unless �a dispute or ac�ion is pending vr additional data -on <br /> you .has been collected. <br /> H. you may be reauired to pay actual costs in �aking� <br /> certifying and/vr com�iling the copies o= in=orivation <br /> requested. • <br /> Date of Request: <br /> r • �f, ..,... ,.� . . <br /> —1"`�,�. '��„ � .r i ..4'� ',1 :, S F`� .,.. <br /> Requester Name? �- � • <br /> . City: <br /> Ar3dress: <br /> Z , . <br /> Z�7- 4 �> r-+ d ' ' ' l'' • � ��"l� '�', T C`',l�•. ,�"` (�' {�� L-�`'—`� ..`.�:.�• ',� <br /> ,`> � �, 1 ; � �..f ,... � �,��-�_: Business *�f�` <br /> Home Phone: �_� '� ,,_ ,/� ��� � � � / <br /> I �; 11 � ki�✓I"VL C.��.'r-'`- r� ' v <br /> Descript=-on of ���a�'�n Re�ested: <br /> Reuueste.r'. s Signature: <br /> BEI,OW S27gOR�`�1ATION TO BE FII�LE� IN BY DEPARTI�NT ONLY <br /> Handle3 sy- <br /> D ep art��t= <br /> Mais. Phone <br /> geqaest 7.'ype� _In Persan . — — <br /> gecsues�ed By: — <br /> Subjec� o= Data Not Sui�ject o= Data <br /> �ublic Private <br /> Tnfosmation Reqaested is Classified: _ <br /> Non-�ubl.ic -rotected Non-Public <br /> Con=idential — <br /> Aporoved Denied P_aproved in_Part <br /> gequest is: _ — <br /> gemarks/Camments: <br /> � � � <br /> Anthorize3 Signat�re: <br /> _ $ <br /> Fees:• X Total Due ._ <br /> No. of Pages Rate per Page <br />