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ORONO ADMINISTRATIVB OFFIC$S <br /> INFORMATION DISCLOSDRE REQIIEST <br /> MINNESOTA GOVERNME1�iT DATA PRACTICSS ACT <br /> R�UESTER 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: I ' z� � v` I <br /> Reqnester Name: �0�` c , c �- • �10 � �� <br /> 3 ��0 ('`��.1 -t-: �� s i�.a�� � �s <br /> Address: �'..� Sa , lo � 5�-�e e-F City: • <br /> zip. �5 �-U 2. <br /> . <br /> Ho�e phone: '���- - g I 7�J susiness: 3�'� � 0 23`� <br /> Description of Information Requested: �� ( � C��'�+e'�{5 ' <br /> �.� � � '� 2� � GJ P2 r��� �A�n e <br /> Requester's Signature: �'Y\C� �• <br /> BELOW IPFOR1rIATION TO BE FILLBD IN BY DEPAR ONLY <br /> Department: Handled By: <br /> Request Type: In person Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Reaarks/Ca�ments: <br /> Authoriaed Signatnre: <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due � <br />