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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSDRE REQDEST <br /> MINNESOTA GaVERPIlK.BNT DATA PRACTICES ACT <br /> gEQIIESTER NOTE: <br /> A, Request Frequency - Private Data on individuals. After the <br /> have been supplied the data and informed of its meaning, <br /> data need not be disclosed to you for six months thereafter <br /> unless a dispute or action is pending or additional data �on <br /> you has been collected. <br /> B, you may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies ot information <br /> requested. <br /> Date of Request: 2 \ `�� � <br /> Requester Name: �1���.Y� � ����C�h �-='-,-� "� `, � <br /> Address: �2� �J•`nC-e �1�5 �"�'�r� City: �� \Y��1 <br /> zip- ����{�S <br /> Home Phone• �� 1 ' ��� � Busines s: ��S�"��� <br /> Description of Information Requested: <br /> ".� . _ �V L l� c�`� ` `(\�C:•�V✓�C�: � <br /> , �,1��� ��c�,� � �� <br /> � � <br /> Requester' s Signature: <br /> BEI�OW INFORMATION TO BE FILLED IN BY DEPART�:NT ONLY <br /> Depart�.ent- Handled By: <br /> Request Type: In person Mail Phone <br /> R ested B Subject of Data Not Subject of Data <br /> � y: <br /> Info=mation Requested is Classified: <br /> Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: APP <br /> roved Denied Approved in Part <br /> Remarks/Co�ments: <br /> Authorized Signature: � <br /> Fees:. X $Total Due <br /> No. of Pages Rate per Page .- <br />