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. <br /> ORONO ADMINISTRATIVE OFFICES • <br /> 1"NF'ORMATION DISCLOSURE PR CISC'SS ACT <br /> • • MINNESOTA GOVERNMENT <br /> • REQUESTER NOTE: <br /> you <br /> A. Request Frequency - Private Data on individuals. After tou <br /> have been supplied the data and informed of�its meaning,onthsthereaftere <br /> data need not be disclosed to yendina or additional data -on <br /> ou for six Bless .a dispute or action isp <br /> • <br /> you .has been collected. • <br /> You may be required to pay-actual costs in making, <br /> B. the copies of information <br /> certifying and/or compiling <br /> requested. <br /> 573/ <br /> O <br /> Date of Request: <br /> Requester Name:. A�..�. -. 1111111. <br /> (.0 <br /> • __Ale' ' , City: )A6 <br /> Address: • <br /> zip: • <br /> Business: <br /> Home Phone: <br /> If o ation R- 1ested:. 1 _= <br /> Descr ' ay on " <br /> . f" f .41 f / -.4g.t <br /> Requester's Signature: <br /> BELOW INFORMATION TO BE FITTED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Mail Phone <br /> Bequest Type: In person — <br /> Subject of Data <br /> Not Subject of Data <br /> Requested By: — <br /> Information Requested is Classified: <br /> Public Private <br /> Non-Public Protected Non-Public <br /> _Confidential in pat <br /> Request is: Approved <br /> Denied Approved <br /> Remarks/Coamaents: <br /> di Q ---�/;ems-..---'zed Signature: f / • <br /> ,70''' <br /> Authorized <br /> Fees:. x Total Due <br /> No. of Pages Rate per Page <br />