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ORONO ADMINISTRATNE �FF=�S � <br /> =3�7F'pRMATION DISGLOnA�EPR CTICES gCT <br /> � MSNNESOTA Ga <br /> • gBQIIEST�Ft NOTE: . <br /> A. Recruest Frequency - Private Data on individuals. A�te= Y°u <br /> have been suppli.ed the data and infor.�ed of its aeaning, the <br /> data need not be discl.osed to you for six aont:ns thereafter <br /> unless `a dispute or ac�ion is pending or additional data -on <br /> you .has been col.lectea. <br /> H. you may be reauirec to pay actual cos�s in making, <br /> certifying and/or cout�iling the copies o� in=ormatior_ <br /> requested. • <br /> Date of Request: � b o <br /> , . . <br /> W -' <br /> Requester Name= � <br /> Ac3dress: 3�, WE�TW <br /> OC7YJ ��l V{� Citv: '_.f7�u L�� <br /> Z ip: 6'�"�3 SZ� 1^L��-�`J�.�". � � <br /> _ � <br /> Business: SCo 5-�- <br /> Home Phone: ��l'�.1 `��'� '�'�O_.�_ �, <br /> r � ��,(.� �� <br /> Description of Inf ormat�'on Rea_�ueste3: �� �l J � �' <br /> Y � . � <br /> Reuuester'. s Signature: <br /> BgyOW Ir7gOFtMATION TO BE FII,I�E� IN BY DEPAR'�N� OrTt'Y <br /> $�alea sv: <br /> Depart�ent= <br /> Mai1. Phone <br /> gequest Type- _In Persan . — <br /> gequested By: <br /> Sub j ec� o= Data Not Stw j ect os" Data <br /> TnfoZmation Requ <br /> ested is Classified: ?un7-=� Private <br /> Confidential Noa-?ublic <br /> =rotec�ed Non-Public <br /> Approved Denied F�proved in_Part <br /> geqaest is: -- <br /> Remarks/Comrments: <br /> � � i C.:�.�-c�..���- ��������� <br /> Anthorized Signature: <br /> _ $ <br /> Fees:• X Total DLe .. <br /> No. of Pages Rate per Page <br />