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ORONO ADMINSS�RATSVE OFFSCES <br /> INF`ORMATION DISCI�OSIIRE RE4�ST <br /> I�4SNI�TESOTA Ga DATA PR�CTICES ACT <br /> gEQIIES�FjR NOTE= - <br /> A. Ftequest Frequency - Private Data on individuals. After y°u <br /> have been supplied the data and informed of its meaning, the <br /> data need nvt be disclosed to you for six months thereafter <br /> unless a dispute or ac�ion is pending or additional data -on <br /> you has been collected. � <br /> B, you ivay be reauired to pay actual costs in making, <br /> certif ying and/or compiling the co�ies oi iniormation <br /> requested. - <br /> Date of Request: �L '� <br /> ' �r y� � f.� <br /> Requester Name= � � <br /> city: u'�'fi� <br /> Address: �-"� ' ��--� <br /> zip: F�3`L1 <br /> , , � �v��...,�.���?' <br /> Z`� Phone= �� ����-i Business:—( � � �w"Z-�- �"���" <br /> Description of Information Reuuested: <br /> .� <br /> � , <br /> Requester'. s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPART2�NT ONLY <br /> Handled BY: <br /> D ep ar-tment= <br /> Mail Phone <br /> ge�quest Type= In persan — <br /> Subjec" of Data Not Subje�� or Data <br /> gequeste3 By= ` <br /> ?ui�Iic Private <br /> Information Re�quested is Classified: — <br /> NaII-�ubZ�� =rotected Non-Public <br /> Cons"idential <br /> Approved Denied P_pproved in_Fart <br /> gequest is: _ — <br /> Remarks/Cau�ents: <br /> Au-thorized Sign.ature: <br /> = S <br /> Fees:� X Total Due __ <br /> No. of Pages Rate per Page .. <br />