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ORONO AD�iZNISTRATNE �FFICES <br /> I3`7FORMATION DISCLOSIIRE KEQUEST <br /> MSNNESOT�. Ga DATA PR�CTI�ES ACT <br /> ' gLQIIEST�R NOTE= <br /> A. Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, <br /> the <br /> data need not be disclosed to you for six montns thereafter <br /> unless a dispute or action is pending or additional data -on <br /> you has been collected. <br /> g, You may be required to �n�ythet copies�so= in orm tion <br /> certif ying and/or compz 1 g <br /> requested. - <br /> Date of Request: ' �` �c <br /> Requester Name: ` < � ~�� . <br /> 2 G�'� ���� �,— ��ty: ��—��� <br /> Aaaress: � <br /> _'��r/ <br /> Zip- �e � _ ,/ 6-- — �� <br /> � � `� `�� Business- '�`�� � <br /> gome Phone: ��7� , <br /> ' ��� <br /> Description of Information Reuuested: „ <br /> � -- .�22� �i' <br /> Re�uester`. s Signature: 'L�' ' " <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTME?NT ONLY <br /> Handled Bys <br /> Department: <br /> Reqnest Typ <br /> e: In person Mai1 Phone <br /> gequested By: Subjec� of Data <br /> Not Su:n j ect of Data <br /> �ublic Private <br /> Information Re�quested is Classified: — <br /> Conf idential <br /> Non-?ublic -rotected Non-Public <br /> gequest is: <br /> Aporoved Denied Approved in Part <br /> Rem.arks/Comme�ts: _�l'� ' � <br /> � <br /> f- ,.,.�. ?� `�%;�' G��-�S�'- /�:�' <br /> . �� �4�s��./��'�--� <br /> Authorize3 Signature: <br /> _ $ <br /> Fees:• X Total Due <br /> No. of Pages Rate per Page <br />