HomeMy WebLinkAboutrequest for info ORONO ADMSNSSTR.ATNE OFFSCES �
INFORMATION D7TSCLDA� PR CTICES ACT
• � �4�INESOTA Ga ,
• ggQUESTE�Z NOZ`E= .
A, gecruest Frequency - Private Data on individuals. �'��e'-" th�
h�.ve been supolied the data and uf f�esixf�on�se�ereafter �
Qata ne�d not be disc?osed to y
. .�r_�ess .a c3ispute or zc�r..on is �pending or additional data -on
you .has been col.I.ectec. -
you may be reauirec to pay��actual cos�s in uzakinQ.
B. zhe copies or in=oraati-or
certifying and/or co�niling
requested. '
� _ � �� _ oi ,
Date of Request:
� � ��M�S � + ��'��� S��/�
Reqaester Name: .
�ir3cZress:
� �no ��/�-T�i� Tow� d��- City: ;�1A�� � I��I�IN
� Z ip: 5 5 -' ��
SZ- y7 � - � 1 S1 Susiness:
H�e Phone= `� =
Ui�pi�✓� ���i �irs �-
Descr�p�=on of 2nformation Recruested: . a S C I-+ 1P�� 1��R '
N � V� ���' �� s o� � ,� c� Cl� PP�C�-% .
ReuIIester`. s Signature: . wl-"
BFyOW INgORMATION a-- E FI I BY DEPAR�M-°NT O2TLY
Depar:�ent= C�� 2--
Handlea. bY= 'v
Mai1 Phone
gequest Type= __�___In Pe'-"son . — —
g�ested By: _Subjec� o= Data
pC Not Sui�j ect of Data
;n.foraation Requested is Classified:
D� �ublic _Private
�;o�-?ubli.c _=rotected Non-public
Con=idential — - ;n pat
Denied A�proved _- -
gecruest is= C�=APProved —
Remarks/Co�.ents:
Anthorized Signatare: �
_ $
x Total Due „
Fees:• e5 R�t� per Fage
No. of Pag .