HomeMy WebLinkAboutrequest for info ORONO ADMINISTRATNE �FF=�S �
=3�7F'pRMATION DISGLOnA�EPR CTICES gCT
� MSNNESOTA Ga
• gBQIIEST�Ft NOTE: .
A. Recruest Frequency - Private Data on individuals. A�te= Y°u
have been suppli.ed the data and infor.�ed of its aeaning, the
data need not be discl.osed to you for six aont:ns thereafter
unless `a dispute or ac�ion is pending or additional data -on
you .has been col.lectea.
H. you may be reauirec to pay actual cos�s in making,
certifying and/or cout�iling the copies o� in=ormatior_
requested. •
Date of Request: � b o
, . .
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Requester Name= �
Ac3dress: 3�, WE�TW
OC7YJ ��l V{� Citv: '_.f7�u L��
Z ip: 6'�"�3 SZ� 1^L��-�`J�.�". � �
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Business: SCo 5-�-
Home Phone: ��l'�.1 `��'� '�'�O_.�_ �,
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Description of Inf ormat�'on Rea_�ueste3: �� �l J � �'
Y � . �
Reuuester'. s Signature:
BgyOW Ir7gOFtMATION TO BE FII,I�E� IN BY DEPAR'�N� OrTt'Y
$�alea sv:
Depart�ent=
Mai1. Phone
gequest Type- _In Persan . —
gequested By:
Sub j ec� o= Data Not Stw j ect os" Data
TnfoZmation Requ
ested is Classified: ?un7-=� Private
Confidential Noa-?ublic
=rotec�ed Non-Public
Approved Denied F�proved in_Part
geqaest is: --
Remarks/Comrments:
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Anthorized Signature:
_ $
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