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" + • ORONO ADMINISTRATNE �FF=CES <br /> INFORMATION DISCLOSURE RE4IIEST <br /> � I�SNNESOTA Ga DATA PR�CTICES ACT <br /> • gLQLTES��R NOTE: � <br /> A. Reauest Frequency - Private Data on individual.s. Afte= Y°u <br /> have been supplied the data and infor�ed of its meaning, the <br /> data need aot be disclosed to you for six montns thereafter <br /> �unless a dispute or action is pending or additional data -on <br /> you .has beeri col.Iected. <br /> g, you may be reauirec. to pay actual costs in �aking• <br /> certifying and%or comailing the copies o� information <br /> requested. - <br /> Date of Request: �` �`� ��' L,� ���� <br /> ` . � , l--� , � � � <br /> Requester Name: �' v � � ��� ' ��; <br /> -� . �-''-�_�.-� City: <br /> Address: � � �c C, `— `� � � C�- <br /> z��: ��i� �i I ��� �� <br /> Ham <br /> e Phone: Business: �_��Z � <br /> Description of 2nformation Reuueste3: <br /> , ��_-Y--- i----- . <br /> � - <br /> gequester'. s Signature: <br /> ���.-�_ ����� ' <br /> Bgypy7 INFORMATION TO BE FII�LED IN , Y DEPARZ'MENT ��'Y <br /> Han.dle3 sy: <br /> Department: <br /> ge�aest Type: _In Person . <br /> Mai1 Phone <br /> gequested By= <br /> Subjec� of Data Not Su�ject of Data <br /> =�oz�ation Re�u <br /> ested is Classified: �u�li� Private <br /> NaR-�ubli� :rotected Nan-Public <br /> Conf idential <br /> Aooroved Denied Approved in_Part <br /> ge�qaest is: — <br /> Remarks/Camme�ts: <br /> Anthorized Signat�re: <br /> _ $ <br /> Fees:. X TotaZ Due .. <br /> No. of Pages Rate per Page <br />