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ORONO A.DMINISZ'RATIVE OFFICES <br /> INFORMATION DISCLOSD�ZE KE4IIEST <br /> MINNESOTA GO DATA PRACTICES ACT <br /> REQIIESTER NOTE: <br /> pl, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, the <br /> data need notube o�sac°Son is pEnding or add tional edatat-on <br /> unless a disp , <br /> you has been col.Iected. <br /> g , you may be required to pay actual costs in making, <br /> certifying and/or compiling the copies oz information <br /> requested. <br /> ,�- - - „-<,: � <br /> Date of Request: -- - ;; <br /> ' '�c�'. '�:�'" T ,�'=1�,�_' �c- K� Cl2/ <br /> Requester Names <br /> � -�-� �� ,�:yti�,� �e� i� �'1� City: ' �, j� _>�=�-'r'1� <br /> Address: '�4st - <br /> Zip: �� '�� � — <br /> ' Business: `/ � :�- = � `�- `� <br /> ���-- � ;�z�. -� <br /> Home Phone- � ' � "' <br /> Description of Information Re�quested: i��'l��>���''�'rl��'�� <br /> � � -� . � �!�,�-J G{�iCS-O a� <br /> �� �' C-/9>°� 1� j/t��Y � � �' <br /> i' - .-` <br /> / � ��.�f� ' � ��:� ta-�-�_ <br /> Requester'. s Signature: / ' �' �� " - <br /> BELpW INFORMATION TO BE FI7,ZED IN BY DEPARTI�:NT ONLY <br /> Handled By: <br /> Department: <br /> In erson Mai1 Phone <br /> Re�quest Type: P <br /> ested B Subject of Data Not Subject of Data <br /> Re�qu Y= <br /> Information Re�qu <br /> ested is Classified: ?ublic Private <br /> Confidential Non-�ublic =rotected Non-Public <br /> gequest is: Approved Denied Approved in Part <br /> RP�narks/Conffients: <br /> Authorized Signature: <br /> _ $ <br /> Fees: X Total Due <br /> No. of Pages Rate per Page .. <br />