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` Y OF ORONO � ,;:
INFORMATION DISCLOSURE REQUEST �-.___._,
Minnesota Government Data Practices
A. :�JF'ST�2 �LETE (it 1- ) -_ �
1. Date of R�u�t _,L ;y ,�,_,_ AEOUESTER NOTE: •
2. Requ�ster Name (L�st, fir,$ , middle) • � �
A. Fpue�t fr�Quenty—Priv��e D�ta on�nd�.;Cuafs.A'ter rou!►�.�peen�
�'�� ���� ��v� , the c1�a anC inlorm�d of�ts mtsn:.�,IM O�a�eW no�0�O�u'oa�s b
sia man►ns tne�u�ier un�ess�E��puu o�ac��on i�peneu�p w aaC.�w�w
3. AddL�25S (lf I�EEd@d) on yo�'+a�DN�co���tted, •
� � /S� 8. You mty b�rspuireQ to pay tM�ctwt costs of makin0,tariifr�n9 anG�p
tpmpd�n9 IA�top�ts OI�nformstipn rpu��teC.
. Phane (if n�eded) �� - _
C/ s a'-7�c�5 cn C3"I-�j/ � Driver's License #�.����.5�7�-/y4
5. D�s cripti� of the infonnat.ion requested '-
�E/UEiPAL %Ui._:iF'ALC- O J'fLOC�K C3/cJ G�c����7`�, /��/ /t/d�H �.'�',�' •Y',-/-�� /�C/CLU.i�//(i(
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/�L-S/���%s�ii�it/� �?'v�� G� o��G'19'c�2%."� 04��c�
6.Reques r Signat
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B. DEPAR OCNIPLETE ,
7. Department: ' , �' '�_ 8. R�uested x�dled /1�Q� �T�,,r
9. Request Zyp�: In person Mail Phoa�e lO.Re�uested by: ,�i'�ub ect of Data . .
Not s�ject of Dacta
11.Inf tion Requ�.sted is classfied: 12.R�quest:
li c Non-publi c App�ved Deniecl Approved in Part
Private Protected Non-p�lic (explain in 14)
Confidential 13. Authorize'�-'�''�
�ignaturn - �
14. REMAR�CS - C�]TS �" �
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C. DEPARTMENI' CCMPLEI'E WHEN FEFS ARE ASSESSID (Reoeipt to be issued)
15. Fc-�s s Flat Rate X * 16. Fees-Researd�/Statmaxy
# of Pgs Fees-Screening of Files
*See current fee s dzedule
17. ZUI'AL AMOt7NT DUE $ Rec'd By Date
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RFJQ�tJFSI'ER PLEASE NO'I'E ITII�iS �
1. Make money order/d�edc payable to City of Orono.
2.� If mai 1, return entire form and any fe�s to: