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ORONO ADMINISTRATSVS OFFICES <br /> Ir7F'ORMATION DISCI,OSURE REQIIEST <br /> I�iINNESOTA Ga DATA PRACTIC�S ACT <br /> REQIIESTER NO�E- . <br /> A, Request Frequency - Private Data on individua?s. After you <br /> have been supplied the data and u£foresixfmonthsethereafter <br /> data need not be disclosed tO yending or additional data -on <br /> unless a dispute or action is p <br /> you has been collected. <br /> g, 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: �- - � ��"-9 <br /> Requester Name: � <br /> � ( O City: <br /> Address: "T <br /> Z ip- �� <br /> gome Phone: g 3 � � � �� _ Business: ��" � ^ � 7� � <br /> Description of Information Requested: <br /> � <br /> ---__ <br /> Re�uester' s Signature: � <br /> gELOW INFORMATION TO BE FII,I�ED IN BY DEPARTMLNT ONLY <br /> Handled By: <br /> Department: <br /> In erson Mail Phone <br /> Re�uest Type: P <br /> ge�uested By: <br /> Subjec� of Data Not Subject of Data <br /> Information Requested is Classified: <br /> ?ublic Private <br /> Confidential <br /> Nan-�ublic =rotected Non-Public <br /> ge�uest is: Approved Denied Approved in Part <br /> gem,arks/Comments- <br /> . ��. <br /> Authorzzed Signature: .. <br /> i` .�`'''• - $ <br /> Fees: X Total Due <br /> No. of Pages Rate per Page .. <br />