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ORONO ADMSNISTRAT2VE �FFICES <br /> =3�7E'ORMATION DISCL�SIIRE R�Q�ST <br /> � IS2NNESOTA Gati�� DATA PR�CTICES ACT <br /> • g�QIIES�ER NO�Es - <br /> A. Reauest Freauency - Private Data on individuals. Afte= Y°u <br /> have been supplied the data and informed of its meaning, the <br /> data need not be disclose3 to �'eIIdina or �ddit onal edatat-on <br /> �unless `a dispute or ac..ion is p <br /> you .has been col.Iected. <br /> H, you may be reauired to pay �actual costs in �aking� <br /> certifying aad%or compiling the copies o= infor��tiOn <br /> requested. - <br /> Date af Request: b b �m0 <br /> Requester Name- � . <br /> Address: �Q w �''(1�lLOcS� �� V� ity' �� <br /> ��� �-� — ,Y'�e�-a�'�`" -� <br /> Zip= � <br /> e Phone: lol� �� � 6� Business. �C� �-•��- � , <br /> $� � � � <br /> Description of Information Reffuested: <br /> ? �'�/_5 ,i�-���� �4�'.�-� � <br /> Y . � <br /> gequester'. s Signature: � <br /> BEI�OW SNFOR�`SATION TO BE FII�LED BY DEPA�ZTMSNT ONLY <br /> sanaled By= <br /> Depar�ent= <br /> Mai1. Phone <br /> ge�aest Type= _In Pe=sc^. . — <br /> gequested By= _ <br /> Subjec� o= Data Not Sunject os" Data <br /> ested is Classified= �u�Ii� Private <br /> Tnfozmation Reqa — <br /> Conf idential Non-?�Zic <br /> =rotected Non-Public <br /> Aoproved Denied Anproved in_Part <br /> g�quest is: _,_ — <br /> Remarks/Ca�ents: <br /> � �+ <br /> ! , , ,t� �•fr-f'-�-n'-�,q l � Q ,/�7 <br /> Antb.orized Signa <br /> tBre: 1,��� ' ! (J u �.���., v���-�.. <br /> = S <br /> Fees:• X Total Due .. <br /> No. of Pages Rate pe= Fage <br />