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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMYNT DATA PRACTICES ACT <br /> REQUESTER 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 not be disclosed to yendinQ or addzt onalou for six months edatat-on <br /> actioner <br /> unless `a dispute or is p <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. �j . <br /> Date of Request: /,// / L� <br /> Requester Name: <br /> ()' •� CCS I/ZLJ <br /> 1 <br /> !<_ / <br /> Address: . City: /L.0 <br /> / /C! �% / <br /> Zip: <br /> / <br /> Home Phone: ''� ' L/6/ � d <br /> Description of Tnformation Reuuested: '..__ _1 ( <br /> 7. <br /> Requester's Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: <br /> Z Handled By: V' <br /> Request Type: 0( In person <br /> Mail Phone <br /> Requested By: Subject of Data U� <br /> Not Subject of Data <br /> Tn-Formation Requested is Classified: Pe- Public Private <br /> Confidential <br /> Non-Public Protected Non-Public <br /> QCApproved Denied Approved in__Part <br /> Request is: _ — <br /> Rema rks/Courments: <br /> ' / Ai <br /> Authorized Signature: • <br /> = $ <br /> Fees:• x Total Due <br /> No. of Pages Rate per Page <br />