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ORONO ADMINISTRATIV� OFFSCES <br /> INFORMATION DISCLO�S�II�p���S ACT <br /> �+SINNESOTA GaVERL�SSNT ` <br /> �Q�S� N��� - Private Data on individuals. After you <br /> A, Request Frequency the <br /> have been supplied the data and inforuted of its meaning, <br /> data need not be disclosed to you for six montns thereafter <br /> unless a dispute or action is pending or additional data �on <br /> you has been col.Zected. <br /> g , You may be required to pay actual costs in making, <br /> certifying and/or compiling the copies or information <br /> requested. <br /> Date of Request: �'�� / ��� <br /> ` I� '�` i� <br /> Requester Name: <br /> � <br /> � City: � <br /> Addre s s: �e� <br /> z�P: ��-� �f 3 _ a l S� <br /> �"'3�, �3 y/ Business = ��� <br /> Home Phone: �� <br /> e s t ed: ���f /� a: ,�1-�� �` aJl�� <br /> D e s c r i p t i o n of Information I��qu - U <br /> I � <br /> � \ 1 +/ <br /> � ' ' � �-�� <br /> �- � � ��.. ,� ' /$ p <br /> � ature: • �.� �� � � - <br /> Requester s Sign <br /> BELOW INFORMATION TO BE FII�LED IN BY DEPAFZTMENT ONLY <br /> Han.dled By: <br /> Department: <br /> gequest Type= In person <br /> Mail Phone <br /> Requested By: Subject ot Data <br /> 27ot Subject of Data <br /> Information Reqaeste3 is Classified: <br /> Pub�ic Private <br /> Confidential <br /> Non-Public =ratected Non-Public <br /> gequest is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> _ $ <br /> Fees: x Total Due <br /> No. of Pages Rate per Page . . <br />