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� OROHO ADMS�I2S2`R�TSYE OFFS�ES • <br /> �TFaRMATION D=SdDATA PR CTSCES ACT <br /> • � �Sh'2v'ESOTA GO . <br /> • gpQUES��K NOTE= " ' <br /> g_au.est Frequency - P�ivate Data oa individuals. ��e= th� <br /> A. n <br /> have been supplied the data and uf fQ es�fIIonz.:nsethe e�fter � <br /> azta ne�d not be disclosed to y <br /> . � . .unless �'a di.spute vr ac�ion is -pendiva or additioaal data -on <br /> .� you .has� beea. co1lectea. . _ <br /> y ouu may be reauired to pay��zCtu�Z �COS�s in �aking; <br /> B zhe co�ies o� in=orrsation <br /> certifying and/or co��iling <br /> =equested. 12 • ' <br /> � 1 ' <br /> Date of Requests _ <br /> � N�e= �� �� � ��., • <br /> quester <br /> R� ) '1 .�.�� Ci-ty: � ' � � <br /> Aaar�S�: C��� � �'i 1Z�� 1�i��� <br /> . �� �� � /� / <br /> ZiD: C'J�� ��'�'�jl � l <br /> gusi.ness: r <br /> Hame Phone= <br /> Descript�-on of �-f°�a��II R��esteds. <br /> �n%//�-�� . <br /> � . . <br /> . i ��,�,�� �. � <br /> � Recruester' s Signa�.�.e: <br /> BELOW SNF ^} <br /> ORMATION TO BE FII,I�E� IN BY DEPARg=''x� O�'Y <br /> D ep ar`.�ent: _�%�f�+-�-�^' <br /> Hand.led Fg= l��`°`-' <br /> Mail. phone <br /> gec�uest Type= __In perso_^. -- — <br /> R�eS`ed By= —Subjec� of Data <br /> Not Su:o3ect oi Dzt� <br /> � �u:Dl.ic _ private <br /> �fo�a�on Requested is Classified: — <br /> public <br /> Na�-�ublic _=rotected Nan-- <br /> Conf idential — . . � � � _ � Part <br /> Denied � Fnnroved n_ <br /> Rea'aest is: �, Aooroved — — . <br /> g�* arks�Ccjarme�.ts: �� "� . <br /> ���_�_� _ �� <br /> �,, ,, ;� � ,(%.G�� l �`� <br /> � -L�i <br /> Bre: C�'"� • <br /> ���orizea Sig�t = S <br /> X Total Due „ <br /> Fees:• ., e5 Ftate per Page . <br /> xo. of Pag . <br />