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ORONO ADMINISTRATNE �FFICES <br /> INFORMATION DISCI�OSIIRE REQIIEST <br /> MINNESOTA Ga DATA PR�CTICES ACT <br /> ' gEQIIESTER NOTE: . . . . � <br /> p,, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, <br /> 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 collectefi. <br /> g. You may be required to pay actual costs in making, <br /> certifying and/or comailing the copies oi inf ormation <br /> requested. � <br /> Date of Request: � �� �� " <br /> � � �a,h-���:� � ��%�`- <br /> Requester Name: ^ Cz� <br /> Address: <br /> �,� � �, �,�+'". city: �• C�O <br /> Zip: �� � <br /> Home Phone: J`t`!"� (��� Business: <br /> Description of Informatioa Re�quested: <br /> - (.� o�-. ���e.�4 �{OC�� lv . �.-�r'� � . <br /> I� <br /> O r���� <br /> _ _ � ��� <br /> Requester: s Signature: <br /> HELOW INFOFtMATION TO BE FII�LED IN BY DEPARTMSNT ONLY <br /> �j �2 Ha.n.dled By: <br /> Department: - <br /> In erson Mail Phone <br /> �tequest Type: �_ P — <br /> ested B Subjec� of Data _�_Not Subject of Data <br /> Ftequ Y= <br /> Inf ormation Requ <br /> ested is Classified: �_��Ii� private <br /> Confidential Non-�ublic =rotected Non-Public <br /> Re�quest is: �Approved Denied Approved in_Part <br /> Remarks/Camme�ts: <br /> Authorized Signature: <br /> = S <br /> Fees:• X Total Due <br /> No. of Pages Rate per Page <br />