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• <br /> ORONO ADMINISTRATIVE OFFICES • <br /> INFORMATION DISCLOSURE REQUEST <br /> • MINNESOTA GOVERNMMNT DATA PRACTICES ACT <br /> REQUESTER NOTE: <br /> r yo <br /> A. Request Frequency - Private Data on indi i ditss. Afte you <br /> have been supplied the data and ouffored ofor six months thereafter - <br /> data need not be disclosed to yendinQ or additional data -on <br /> .unless :'a dispute or action is -p <br /> you .has~ been. collected. <br /> ' <br /> in <br /> You may be required to pay-actual <br /> c so s f in making, <br /> certifying <br /> B. and/or compiling the co_ <br /> rmation <br /> requested. `6/�� 0 <br /> Date of Request: ( <br /> • <br /> • <br /> 411111111" , <br /> Requester Name . n <br /> ��-, 1 , City: a v G�i2p� <br /> Address: (� L'�� �.� �J <br /> zip: <br /> Business: • <br /> Home Phone: <br /> Descr ' ./ 'on •f o ation R- - ested:. <br /> Requester'.s Signature: <br /> BELOW INFORMATION TO BE FILLED <br /> IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department= <br /> Mail Phone <br /> Request Type: In person — <br /> Requested By: _Subject of Data <br /> Not Subject of Data <br /> Information Requested is Classified: <br /> PublicPrivate <br /> Non-Public protected Non-Public <br /> Confidential ____ <br /> Denied Aporoved in_Far v <br /> Request is: Approved — <br /> Remarks/Comments: <br /> • , K_ / <br /> Authorized Signature: ,' • <br /> pees:. ax Total Due <br /> No. of Pges Rate per Page <br /> • 4 <br />