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ORONO ADMINISTI2ATIVE OFFICBS <br /> INFOItMATION DISGLOSURE REQII$ST � <br /> MINI�TESOTA GOVERrIl�LJT DATA PRACTICES 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 inf ormation <br /> requested. <br /> Date of Request: " `� <br /> Requester Name: � ���� <br /> �� G� �� <br /> Address: ��� � - City: <br /> Zip: ����� <br /> Ha�e Phone: y7� 9`7� Busines : 7�ir �o <br /> D ript' n of I ormation Requested: �� L- � <br /> � ;�i � v�,�J�' � <br /> �� � 3� <br /> Reqnester: s Signature: <br /> BELOW INFORMATION TO BE II.I�ED I DEPARTMLNT ONLY <br /> Department: Ha.ndled By: <br /> Request Type: In person Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> Info=mation Reqnested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Co�ments: <br /> Authorized Signature: <br /> Fees:� x = $ <br /> No. of Pages Rate per Page Tvtal Due <br />