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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DIS�LOSIIRE RE4IIEST <br /> 2SINNESOTA Ga DATA PRACTICES ACT <br /> RE4IIESTER NOTE= <br /> A, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, the <br /> data need notube orsaction is pending or add tional edatat�on <br /> unless a disp . <br /> you has been collected. <br /> g, You may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies or iniormation <br /> requested. <br /> , j -, %� <br /> Date of Request: � � <br /> . � � <br /> Requester Name- ;��� '� ' f� ., `" <br /> Address: <br /> _ � ��i� i ' " C �� �� City: � � ( ���.� � , <br /> Zip: `� �- - <br /> , ? <br /> gome Phone: <br /> - � - � ����- Business : � /� _ , r .�' _� <br /> . ested: �`��� �� ` " ��" /���� <br /> Descrzption of Information 8e�u <br /> G �� _ - `� � <br /> .�� � <br /> Re�uester' s Signature: � �--` <br /> BELOW INFORMATION TO BE FII,LED IN BY DEPART�NT ONLY <br /> Handled By: - "' �_` - <br /> Departstent: ��� Z ,� <br /> � In erson Mai1 Phvne <br /> gequest Type: P <br /> R ested B Subject of Data J� Not Subject of Data <br /> � y: <br /> Information Requested is Classified: <br /> i'��ublic Private <br /> Confidential <br /> Non-?ubli� =rotected Nan-Public <br /> ge�uest is: � <br /> Approved Denied Approved in Part <br /> gemarks/Camments- <br /> � <br /> Authorized Sigaature: `"--- <br /> '. _ $ <br /> Fe�s: x Total Due <br /> No. of Pages Rate per Page .. <br />