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ORONO ADMINIS�RATNE OFF2CES <br /> I?�7FORMATION DISCLOSIIRE RE4IIEST <br /> IIINNESOTA Ga DATA PR�CTICES ACT <br /> ' gEQUES�ER NOTE= <br /> A, Request Frequency - Private Data on indivi.dual.s. After you <br /> have been supplied the data and informed of its meaning, <br /> the <br /> data need not be disclosed to you for six montns thereafter <br /> unless a dispute or action is pending or additional data -on <br /> you has been collected. <br /> g. You may be reauired to P�ythetconies So= n=orm tion <br /> certif ying and/or compiling _ <br /> requested. - <br /> Date of Request s '� � �� <br /> � '� i' i� <br /> Requester Name_ .=-� ' �� . <br /> Address: "L �� � <br /> f1�i� n% C3.ty: <br /> Z1P: ��:��C <br /> Hame Phone� ��7 � - `��`�u Busines s: <br /> Description of Information Reuuested: <br /> � � t� `—� '��- <br /> ��i[_ (�z�v c�-� �f`�. �.ti - <br /> J <br /> . __. ... 1 r . <br /> / / <br /> gequester: s Signature: _ !�`<' ,,; .� ✓c �` `�.` � <br /> BELOW SNFOFtMATION TO BE FII,LED IN BY DEPAR22ff.'ZIT ONLY <br /> Handled By: <br /> Department= <br /> In erson Mail Phone <br /> Re�nest Types P <br /> g ested B Subjec� of Data NQt Subject oi Data <br /> �u �'' y <br /> In£orm.ation Req� <br /> ested i.s Classifie3: ?ublic _Private <br /> Confidential Non-?ublic =rotected Non-Public <br /> geguest is: <br /> Aporoved Denied Approved in Part <br /> Remarks/CoIIuaents: <br /> ,� � <br /> Authorized Sigaa <br /> ture: L�%�� � <br /> _ $ <br /> Fees:� X Total Due <br /> No. of Pages Rate per Page •• <br />