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� OR02i0 ADMI3I=S�RAT=VE OFFSCES • <br /> 1�`T'r'ORMATION D=SQ'DATA PR CTSCES �►CT <br /> • � Ii�l`+Zv�SOTA GO , <br /> • ggQUES�EEZ NOZ`E= <br /> A. ge�uest Freque�c� - Private Data oa individuals. ��e= t°�o <br /> have been supolied the aata and uf fo esixf non'r.nset�rea.fte,- . <br /> aata aeed not be discl.osed to Z'ending or additional aata '°n <br /> . � . .unless :•a. c3ispute or ac�ion is �p . . . . . � ' . <br /> � you .has� hee� col.lected. . <br /> you may be reauired to pay��zCtual �os�s in �akinQ. <br /> B. zhe conies o� in=oraztio� <br /> certifying and/or co�ailing <br /> =eauested. l Z � ' <br /> es�: � � � <br /> Date of Req� � �� <br /> � � �� �� � i <br /> gequester Name- . <br /> � � ��� City: n 't ' � -� <br /> p,.r3dsess: �� �/ ����1'11�11� <br /> �� �� - � <br /> Z z�: ��a ���-��r � <br /> Busin.ess: <br /> H�e Phane= <br /> Descript-ion of 2nformation Requested:. <br /> �i��l'��t� . <br /> , � ,., <br /> � �. ��/��� � �� � <br /> � Recruester' s Signa�:�e: <br /> BE,yOW �gpRMATION TO BE FII�LED IH BY DEPARTN�''N� O�'Y <br /> - Hanc"t.led. BY= ��y'�` <br /> �_t ����� <br /> D epar�.eIIt� Phone <br /> . In peYsor_ Mail — <br /> R�uest �'ype= — � — <br /> 7 0� Data Not Subject o= Dz.ta <br /> Sub 'ec� <br /> g�es�ed By= Private <br /> `� �u:ol.ic — <br /> =�o�a�.on Reqaested is Classified: — <br /> 4ublic <br /> Non-?uDlic ="rotected Nan-- . <br /> Con=idential. — . . � . . _ . P�� <br /> -- � Denied � pnproved n_ <br /> Anoroved — � • <br /> ge�ues-t is: — <br /> ge�arks/Ca�m <br /> ents= ' .`-,�'- . <br /> , �' ,,� ��� �,� <br /> �/� �- ��;,� <br /> . . ��� . <br /> �n�ori.ze3 Signa��re: <br /> _ $ <br /> Fees:• ., X er Page Total Due .. <br /> No. of Pages Rate p . <br />