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ORONO ADMINISTRATIVE OFFSCES <br /> INFORMATION DISCLOSURE REQIIEST <br /> MrNNESOTA Ga DATA PR�CTICES ACT <br /> ' REQIIESTER NOTE: <br /> p,, Request Frequency - Private Data on individuals. 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 /> 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: �jl ��'�'��'� �U I � G'� <br /> Requester Name: ���'� ���� <br /> ,�� ( � - (,�,1� S f�'��� �;���,r.����u�ty: <br /> �aaress: � <br /> Zip: Gj/� ��� � � � <br /> J � { A� <br /> � , 1�7/,, - ��/�/,�� Bnsiness : _, �� 2(/- <br /> Home Phone s �� I �� � <br /> Description of Information Re�ueste3: <br /> (���� �( )l'lt , i�.� ) � � �(, ��� <br /> i <br /> , <br /> � Re�aester' s Signature: � ��l �it <br /> BELOW INFORMATION TO � FII�LED IN BY DEPART�?NT ONLY <br /> �;�� �` Ha.ndled By: , � ' <br /> Department: <br /> gequest Typ <br /> e: � In person Mail Phone <br /> g ested B Subjec� of Data ��� Not Subject of Data <br /> �u y' .. <br /> Inf ormation Requ <br /> ested is Classified: � ?ublic Private <br /> Confidential Non-�ublic =rotected Non-Public <br /> Denied Approved in Part <br /> ge�uest is: �Approved - <br /> Remarks/Co�ents: <br /> Authorized Signatnre: <br /> ..� �:�� <br /> _ $ <br /> Fees:� x Total Due <br /> No, of Pages Rate per Page •• <br />