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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOOStRE PRACTICESQST <br /> ACT <br /> MINNESOTA GOVERNMENT <br /> • <br /> REQUESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After the <br /> ou <br /> daeed not supplied <br /> losed to youdata and f fored sixfits monthsethereafter <br /> data needanot ending or additional data -on <br /> unless a dispu�e or action 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. /S-- --- <br /> Date of Request: --7 Z- ) <br /> Requester Name: <br /> ce s' w ij ' c <Se�i/ <br /> y`7 -T-- 61-a#am"vi ; 'n.?;'/� <br /> Address: / •�' City: / <br /> - <br /> Zip: <br /> Home Phone: y 7 / ._7C t <br /> Business: `- e-.2___ <br /> Description of Information Requested: <br /> • <br /> Requester'. s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Depart cent= <br /> Mail Phone <br /> Request Type: In person <br /> Requested By: <br /> Subject of Data Not Subject of Data <br /> Tnformation Requested is Classified.: <br /> Public Private <br /> Confidential <br /> Non-Public Protected Non-Public <br /> Request is: Aooroved <br /> Denied P_nproved in_part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees:. xTotal Due <br /> No. of Pages Rate per Page <br />