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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMENT 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 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. �j <br /> Date of Request: ' . v 7 <br /> Requester Name: �� ` ? <br /> Address: <br /> U!1070 p-(7 7 7 city: /e9vA5/ <br /> Zip: .r-S--- 5 V <br /> Home - <br /> Phone: z/-Z7 r ?2-7. 7 Business: �� - Y6', 6 <br /> Description of Information Requested: <br /> gallialb <br /> IP;Adir <br /> Requester' s Signature41111111916%,K <br /> i1��-�� <br /> iia.... <br /> BELOW INFORMATION TO BE - - 4• IN BY DEPARTMENT ONLY <br /> ----'2_ Handled By: (5• <br /> Department: <br /> Request Type: pe- <br /> In person Mail Phone <br /> Requested By: Subject of Data ONot Subject of Data <br /> equ pe <br /> - Not <br /> Information Requested is Classified: <br /> a Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> • / 6,e,______ <br /> Authorized Signature: v. A <br /> Fees: x $Total Due <br /> No. of Pages Rate per Page <br />