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ORONO ADMSNISTRAT=VE OFFSCES <br /> INFORMATION DISCLOSIIRE REQUEST <br /> I�SINNESOTA Ga 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 neaddistute orsaction is pending or add tional edatat-on <br /> unless P . <br /> you has been collected. <br /> g, 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- �� ��� <br /> �� �2,�-,� �KC���IC��- <br /> Address: %K�-� ��' _ CitY: <br /> Zip: �" ' j� � Z��Z <br /> _ ��-�- 2. � �Z Business: ��� ` <br /> Home Phone� <br /> Description of Information Kequ <br /> ested: ��)�'�� �� ' � ��� <br /> � � <br /> Requester' s Signature: % <br /> BELOW INFORMATION `?�O BE FII,I,ED IN BY DEPAR22+g?NT ONLY <br /> ��s Z Ha.ndled By: ��'• <br /> D epart�ent: <br /> Request Type: �_ <br /> In person Mai1 Phone <br /> R ested B Subject of Data �_Not Subject of Data <br /> eq�u Y= <br /> Inf orm.ation Requ <br /> ested is Classified: �_�ublic Private <br /> Confidential Non-?ubZi� =rotected Non-Public <br /> Request is: <br /> Approved Denied Approved in Part <br /> Re�arks/Comments: <br /> � ^` <br /> Authorized Signature: - `�-�`�'^---� <br /> _ $ <br /> Fe�s: X Total Due <br /> No. of Pages Rate per Page .. <br />