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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSDRE REQIIEST <br /> MINNESOTA GOVERNI�+�2IT DATA PRACTIGES ACT <br /> REQIIESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, the <br /> data need not be disclosed to you for six months thereafter <br /> unless a dispute or action is pending or additional data on <br /> you has been collected. <br /> B. You may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies of information <br /> requested. <br /> � /' ��� <br /> Date of Request: �7 �' � � � <br /> Requester Name: � / �P � ,� /�t 5 � � � <br /> � � � <br /> C' <br /> Address: �� � � �� �_ "� � r��'e E � City: � Cl � a�<t_ <br /> Zip: .�,� -� �� � <br /> Home Phone• � � �} -- `/ (,� (� t� Business: � �� � � � � � <br /> Description of Information Requested: <br /> d� � Lu,���.�a-�G'--( ('�,�L � L� ('% G) /Vk.�'L-��-��-��_-11�4��-i� <br /> / __ _ <br /> Requester' s Signature• '_c-E�e�.-�- � �d�-� ;�� {y ; , , :� <br /> _ __.___ _ ; <br /> BELOW INFORMATION TO BE FII,LED IN BY DEPARTMENT ONLY I _ .. i:;.t� <br /> -i �: - <br /> . ... , !L 1"Y+i+�:� <br /> � � . . .. . .,.� <br /> Department: � �� Handled By: / :`��rt:i;� ��L_G' _ <br /> Request Type: �_In person Mail Phone - -� - <br /> Requested By: Subject of Data _�Not Subject of Data <br /> Information Requested is Classified: �Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: � Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: � <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due <br />