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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSIIRE REQUEST <br /> MINNESOTA 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 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 /> ay actual costs in making, <br /> B. You may be required to p <br /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: <br /> Requester Name: <br /> Address: �- <br /> � �t y i'�Lcity: �. .� <br /> -% <br /> zip: ss3 6 - <br /> Home Phone: Business: <br /> Description of Information Requested: <br /> Requester' s Signature: <br /> BELOW INFORMATION To BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: <br /> In person Mail Phone <br /> Requested B Subject of Data Not Subject of Data <br /> equ Y= <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> P <br /> Request is: <br /> Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees:. x $Total Due <br /> No. of Pages Rate per Page <br />