HomeMy WebLinkAboutrequest for information ORONO ADMSNIS�RATIV� OFFI�S
=NFOgMATION DISCLOSURE R�Q�ST
�INNESa2A � DATp, PRACTSCES ACT
�Q�S� N��� � - Private Data on individuals. After you
A, Request Frequenc�
t e
have been supolied the data and ouf fQ esi�f�on�sethereafter
data need not be disclosed to y
unless a dispute or action is pending or additional data -on
you has been coll.ected. ��tual costs in making,
g, you may be required to P�Y �re copies o= in�ormation
certirying and/or corr�piling
requested. �
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Date of Request: - ��
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: - ��� - .?�.I-�� Li �-''L
Requester N�e= � ,��
CitY: L��'✓/�'�%
Add=e s s: / �L'--,S" ��� 1/'� l���
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zip: �' � y � p. _ `i �,
C�I1 _ J7.SS'� Business: �2l ' 7
gome Phone: �
Description � Information FZequested:
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Re�uuester` s Signature= `
BgyaW INgOgM-�TION TO BE �I�L�D IN BY DEPAR�NT ON�Y
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Depart�n�t=
$equest Type: �� In person
Mai? phone
Requested By: —
Subjec� or" Data ✓� Not Su'r�jec� of Data
Tnfozmation Reqaested is Classified: �
�u�Iic Private
Non-?ub1;c =rotected Non-PuDlic
Considential —
Denied A�oroved in Pat'�
ge�quest is: Approved -
Remar3�cs/Co��ts:
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Si ature: `�'�, ,,�,�-�_- -
Autharize� 9n
.. _ $
X Total Due
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