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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA G40VERIu6ENT DATA PRACTICES ACT <br /> REQUESTER NOTE - Private Data on individuals. After you <br /> A. Request Frequency <br /> the <br /> have been supplied the data and of foremeaning,of its <br /> six months thereafter <br /> data need not be disclosed to you <br /> or additional data -on <br /> unless a dispute or action is p <br /> you has been collected. actual costs in making, <br /> B . You may be required to paY <br /> compiling the copies of information <br /> certifying and/or <br /> requested. <br /> Date of Request: <br /> Requester Name: N4 ;. z�b <br /> Cityfug <br /> Address: <br /> �Ar h�A oc ,psi 3 : <br /> Zip: SOLI 0 <br /> game Phone: <br /> 413 1 b'I Business. <br /> Description of Information Requested <br /> l <br /> Requester' s Signature: <br /> : <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: �f Z <br /> Handled By= *_ <br /> Request Type: v4- In perscn <br /> Mai? Phone <br /> Requested By: — <br /> Subject of Data V Not Subject of Data <br /> �ublic _Private <br /> lnformation Requested is Classified: �_- <br /> _Confidential <br /> Non-Public :rotected Non-Public <br /> Request is: Approved <br /> Denied Approved in Part <br /> Remarks/Ccmatents: <br /> Authorized Signature: <br /> x Total Due <br /> Fees: g Rate per Page <br /> No, of Page <br />