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ORONO ADMIN=STR�TI� OFFI�S <br /> =*7FORM�ITION DISGZOSUFZE R�Q�ST <br /> jiINNESOT� Ga � DATA PRACTICES ACT <br /> ggQIIESTER N�� - p,-i.vate Data on individuals. After you <br /> A. Request Frecruency <br /> t e <br /> have be�n supplied the data and uf foresixf montnsethereafter <br /> data need notube o�saction is pending or additional data -on <br /> unless a disp . <br /> you has been coZlected. <br /> be required to pay actual costs in mak�ng► <br /> B. You may t'r.e copies oz in=ormation <br /> certifying and/or compiling <br /> requested. � <br /> Date of Re�uest: <br /> -�1-�i�' <br /> . �� ��1 , S�� <br /> Requester Name: <br /> ---, C.z.ty: <br /> Address: ��c t��� �°"'� <br /> Z i p: �'�7 S - ��7C� <br /> c <br /> Business : <br /> g�e Phone: .. / <br /> �, /vrt���i n,/1 L(,� �LVt__i'��L�' <br /> � ormation FZeqnested: CIV���� "'" �.. � <br /> Des cription of In.f f�(�f r`c-5, <br /> r [+� 1 i i Gy� ��� o:,�c r�w � <br /> C Ll C '- C � ,7. <br /> �-�-L � G� ' <br /> ester' s Signature: 'I ��Y`�' <br /> �e� IN BY DEPAR�NT ON�Y <br /> Bg�,aW =NFOgMATION TO BE FII�LE� <br /> Handled BY= <br /> De art��t= <br /> � � Phone <br /> Request TyPe= — <br /> In person Mai_. <br /> Requested By= _Subjec� <br /> or Data Not Subject of Data <br /> Tnformation Reqneste3 is Classified: <br /> �ublic _Private <br /> NOR—�uDZ=-� ==atected Non-PuDlic <br /> Considential — <br /> Denied Aporoved in Yart <br /> R�.quest is: Aporoveci — <br /> Remar3�s/Camments- <br /> ; // -� C� <br /> ature: `~- ' . - � .r� <br /> Aut�orize� Sign _� <br /> _ $ <br /> X Total Due <br /> Pees: No. of P g Rate per Page " <br /> a es <br />