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ORONO ADMINISTRATIVE OFFIC$S <br /> INFORMATION DISCLOSIIRE REQIIEST <br /> MINNESOTA GOVERNMENT DATA PRACTICES ACT <br /> REQIIESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, �h� <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 /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: 3!``� 5 Z <br /> , <br /> Requester Name: �� � �C Ne <br /> , <br /> Address: 1��� orC �rC �r� City: ��uNU <br /> Zip: S J.� �i � .�- <br /> Home Phone: �l� `�-�-3 (,�73 - 2.�J�J <br /> Q Business: <br /> Description of Information Requested: �����'�r �f�� ,� �,� �wel� <br /> . , <br /> � , � (/^f � Gr' 1P <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: ls � Z Handled By: c���,,,(� �� <br /> �— <br /> Request Type: -�" In person Mail Phone <br /> Requested By: Subject of Data ��ot Subject of Data <br /> Information Requested is Classified: �Public Private <br /> Confidential Non-Publzc Protected Non-Public <br /> Request is: "� Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: �„C�_ <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due <br />