HomeMy WebLinkAboutinfo request ORONO ADI�iTN2S�RATZVE OF�''=CES
INF'ORMATION DISCLOSDRE RE4UEST
. �SN�ESaTA G� DATA PR�CTICES B.CT
• FtEQIIES�PsR NOTE: .
A. gecruest Frequency - Private Datinfor,�edi ofditssmeaning, the
have been supplied the aata and
data need not be disclosed t� yeIIding or adait onal edatat-on
unless �a dispu�e or ac..zon is p
you .has been col.Iected.
B, you may be reauirec to pay actual costs in makiag,
certifying and%or compiling the copies o� informatior_
requested. •
Date of Request:
� �a `�"�n �jA �..���T._'�,.'�,,,,'�-��,:�
Requester Name: .
City:
p�ddress:
,
Zip: �
�- '��,,;;.. � �",t i-���,S�--��
(� � ? �`� � y ' � a �:� �" susines s: �'O�'S `~� �-�---
Hc�me Phone: �
��r-�-c� -`ti.Q.�--�.�
Description of In.formation Reuuested_ �� �J � , `
Recraester'. s Signature:
BEI�OW SNFORbiATION TO BE FIIS,ID IN BY DEPARTMENT ONLY
Hanaled sy:
D ep art�e.nt=
Mail. Phone
Request Type= _Yn Pe'-'san . —
gequested By= —
Subjec� of Data Not Sui�ject o= Data
7nf otmation Requ
ested is Classifie3: ?ublic Private
Con=idential.
Non-?ublic =rotected Non-Public
Approved Denied P_nproved in_Pa�
g�quest is: —
Remarks/Ca�ents:
Anthorized SignatIIre: G �
= S
Fees:• X Total Due _.
No. of Pages Rate per Page ._