HomeMy WebLinkAbout05/31/2001- Info disclosure request OROl`i0 AD:��32STRATI:VE ��=�°S �
2NFORMATIO:Z D=SCLOSIIRE RE4�ST
• � I�4SNI�ESOTA GO DATA PR�CTICES �CT ,
• ggQTTES�F�R NOTE= .
A. p ecuest Freauency - Private Data on indiv�a���SIIe�ing, th=
ha�-e been suppl.ied the aata and infQr�ed� o-Yon�s thereafter �
nata ne�d not be disc?osed to ye� i�� or zaQit�onsl Qat� .�n
. .un1ess :'a dispute or ac�ion is �p . �
you .has bee� collectec.
you m.ay be reauirec to pay��actual �cos�s in �akina;
H. zhe copies or in=or�zt-Or
certifying and/or co��iling
requested. `�"/�� D -
Date of Request:
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Recruester Name= , ''� ������'�
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Add.ress- U `
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Business:
game phone: � �--�
Descr
' on f o ation R ested: � '
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� Recrues�er'. s Si.gnature:
BgyOW �pORMATION TO BE FII�LED IN BY DEPF��H� O�Y
Handle=:. Fy:
D ep ar`�.�.ent=
Mai? Phone
gec�uest TyPe= —xn Ferson . --
Subjec= o= Data No:. Suz��ec� of Data
ge�ues�ed BY= — ` �
_,.�I.;c _P�ivate
�fo�ati.on Requested is Classified= —
_rotected Nan-Publ.i�
Con=idential tvo�-?ublic . _ .
— -�nroved in Par�
Aoproved Denied --
gecruest is= _ —
Re:aarks/Coarments=
- . �� _ .�._ ��._,.�••'�� _�'��`
gn.�ori.ze3 Signature: �/ `� : ;.,- �
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Fees:• X �o �er Fage Total Due „
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ORONO ADMSNISZ'RATIVE OFF=�S �
i
1�FORMATION DISCLOnS�UREPR 4�I�S ACT '
MSNNESOTA Ga
' gEQIIESTEFt NOTE: .
A. 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 yending or ada tionaledatat-on
unless a dispute or action is p
you .has been coll.ectea.
B, you may be reauired to P�y thet copies Sor inform ti°n
certifying and/or comDiling
requested. �
Date vf Request: J
' � � � ?it,i�
Requester Name= r -
' � City: i2��.�
Address: �
ziP: �i53 / �
gome Phone=
�7�� C�7�U Business: 'y �i ����G/
Description of Information Reuueste3: �
. �; :, � °�C .
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Reuues e . s Signatur .
BgyOW I27gOR��TION TO BE F I�I�ED IN BY DEPARTMENT ONLY
��2 s�.ai�a By: ��.
Department=
Mail Phone
gequest Type= � in pe=son —
Subjec= of Data � Not Subject of Data
gequested By= _ `
Information Re�quested is Classified:
�_?ublic Private
Considential
Non-?ubZ�� =rotected Non-Public
�_Approved Denied P_pproved in_Part
Request is: —
Remarks/Comments:
' 1���/1^^---
Authorizea Signat�re:
= S
Fees:• x Total Due ..
No. of Pages Rate per Page