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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE <br /> pREQQUESSTS ACT <br /> MINNESOTA GOVERNMENT <br /> REQUESTER 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 /> B . You may be required to pay actual costs in making, <br /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: 12, 3o 117 <br /> Requester Name: <br /> 1 (C14."- _ !'t, (l r c) -✓2 City: V=Q cJ <br /> Address: <br /> Zip: <br /> Home Phone: / (p�Z7 y �SZ, _. Business: <br /> Description of Information Requested: l‘a <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Depar Lucent <br /> Request Type: In person <br /> Mail Phone <br /> Requested By: <br /> Subject of Data Not Subject of Data <br /> Tnformation Requested is Classified: <br /> Public Private <br /> Confidential <br /> Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: x Total Due <br /> No. of Pages Rate per Page <br />