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ORONO ADMINISTI2ATIVE OFFICES <br /> INFORMATION DISCLOSIIRE REQIIEST <br /> 1�+iINNESOTA Ga DATA PRACTICES ACT <br /> REQIIESTER NOTE: . . . <br /> A, Request Frequency - Private Data on individuals. Aft'er 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: �2 ^ y � � � <br /> Requester Na.me- � '^^ <br /> � NcLs� ..t <br /> Adaress: � 31 �o� city: o�,'�'� <br /> Zip: <br /> Hame Phones �� <br /> Z - Z o�� Business: s�� <br /> Description of Information Requ <br /> ested: �'r`� �-�,�'" i � d .../ <br /> Requester: s Signature: <br /> BEZOW INFORMATION TO BE FII.LED IN BY DEPARTMENT ONI,Y - <br /> Department: <br /> � Ha.n.dled By: <br /> Request Type: In person MaiZ Phone <br /> g ested B Subject vf Data Not Subject of Data <br /> � y: <br /> Information Requested is Classified: <br /> Public Private <br /> Confidential Non-Public =rotected Non-Public <br /> Request is: APP <br /> roved Denied Approved in Part <br /> Re�arks/Comments: <br /> Authorized Signature: <br /> Fees:� X $Total Due <br /> No. of Pages Rate per Page :. <br />