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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSIIRE REQIIEST <br /> MINNESOTA GOVERNMENT 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 /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: � �/ / <br /> Requester Name: ��f�> �<;,�ir�� <br /> Address: � 7 n,�;3 6�3 � �� '�� 1} L�`17 City: <br /> z ip: -�� �S��v`(, � <br /> Home Phone: S�G 3 5���' i susiness: �f �S^ Z �{ l / <br /> Description of Information Requested: _�� .r�-. �� ` � <br /> /�o C� ,���-�- ��t.-��� <br /> °� �� �P ��i,e�. -�-�� <br /> Requester' s Signature: ,�_._.-� <br /> BEIAW INFORI�IATION TO BB FILLED IN BY DEPARTMENT ONLY <br /> Department: Handled By: <br /> Request Type: In person Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due � <br />