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ORONO ADMINISTRATNE OFFS�S <br /> =NFORISATION DISCLOSURE �Q�ST <br /> �iINNESaTA C� DATp, PRACTICES ACT <br /> REQUESTER NO�E: <br /> A_ Reques� Frequency - Private Data on individuals. After the <br /> have been supplied the data and �fforesixfmontnsethereafter <br /> data need not be disclosed to y <br /> unless a dispute or action is pending or additional data �on <br /> you has been coll.ected. zC�ual cos�.s in making, <br /> B . vou may be required to P�Y `re copies os information <br /> certifying ar.d/or compiling <br /> reguested. � <br /> S� <br /> �,�'���� � - <br /> Date of Re�nest: <br /> Keq�ester Name: � ��` ��. � � .1 <br /> Ad <br /> dress: � ��'� City: l-� `�`Z <br /> zip: -���i I/ _ ^ ,� . <br /> ��.-���—/G'�`� Business: <br /> �f�`� �-�: �Z Z <br /> g�e Phone: � � <br /> ��.��{���C..� '�� <br /> Description of Informat�on R�?uested: � <br /> G� � � <br /> � <br /> Gt <br /> i � <br /> �.::��/�/r,_/L;7 �:�i�L��''�i <br /> Re�aester' s Signature: <br /> ,G � <br /> BELOW INFORMATION: TO BE FII,LE� IN BY DEP_z1RT'�'NT ONZY <br /> �' Hasdle3 Bv: <br /> Depart�e.nt= <br /> Reqaest Type= _Tn Pe='sen <br /> Mai? �hone <br /> equested By: Subjec� of Data <br /> Not Sub j ec� of Data <br /> R — <br /> -��� zC Priva�e <br /> =nfoZmation Requested is Classified: <br /> Nor�-�uD1=-c =rotected Von-Public <br /> Conf idential — <br /> Denie� A�proved in Par� <br /> ge�uest is= Approve� — " <br /> Remar�cs/Camments- <br /> Authorize3 Signature: <br /> = S <br /> x Total Due <br /> Fe�s: p es Rate per Page �- <br /> No. o= a5 <br />