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� <br /> ORONO ADMZNISTRATIVE OFFICES <br /> INFORMATION DISCI,OSIIRE REQIIEST <br /> MINNESOTA GOVERNMgNT DATA PRACTICES ACT <br /> REQIIESTER 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 /> � , <br /> C �. <br /> Date of Request: `�'� ���- ��� � � �`-� <br /> '� � •--� � � <br /> Requester Name: /C G� 'S C i r �� <br /> Address: �% j5 c� �� c�Ct � �i �, r�_s� City: �� ��� ��: �c__ <br /> zip: � S �' `/ / <br /> Home Phone: ��'� � L% � % % Busines s: <br /> Description of Information Requested: �- i ���:- -f� � ''Z�� ���'«'" ��'`-�o <br /> �� L ��' ��c _ /�i. .5-��--J ii <br /> __�-_� ^ ' , <br /> Requester' s Signature: �— --�l� � ��c � ��- �� � �z �`�` <br /> BELOW INFORMATION TO BE FILZED IN BY DEPARTM�?NT 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 /> Remarks/Comments: <br /> Authorized Signature: <br /> Fee s: x = $ <br /> No. of Pages Rate per Page Total Due <br />