HomeMy WebLinkAboutRe: request for info ORONO ADMINISTRATIVE OFFSCES
INFORMATION DISCLOSURE REQIIEST
MrNNESOTA Ga DATA PR�CTICES ACT
' REQIIESTER NOTE:
p,, Request Frequency - Private Data on individuals. After you
have been supplied the data and informed of its meaning,
the
data need not be disclosed to you for six montns thereafter
unless a dispute or action is pending or additional data �on
you has been collected.
B, you may be required to pay actual costs in making,
certifying and/or compiling the copies of information
requested. �
Date of Request: �jl ��'�'��'� �U I � G'�
Requester Name: ���'� ����
,�� ( � - (,�,1� S f�'��� �;���,r.����u�ty:
�aaress: �
Zip: Gj/� ��� � � �
J � { A�
� , 1�7/,, - ��/�/,�� Bnsiness : _, �� 2(/-
Home Phone s �� I �� �
Description of Information Re�ueste3:
(���� �( )l'lt , i�.� ) � � �(, ���
i
,
� Re�aester' s Signature: � ��l �it
BELOW INFORMATION TO � FII�LED IN BY DEPART�?NT ONLY
�;�� �` Ha.ndled By: , � '
Department:
gequest Typ
e: � In person Mail Phone
g ested B Subjec� of Data ��� Not Subject of Data
�u y' ..
Inf ormation Requ
ested is Classified: � ?ublic Private
Confidential Non-�ublic =rotected Non-Public
Denied Approved in Part
ge�uest is: �Approved -
Remarks/Co�ents:
Authorized Signatnre:
..� �:��
_ $
Fees:� x Total Due
No, of Pages Rate per Page ••