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ORONO ADMINISTRATIV� �FFICES <br /> INFORMATION DISCI,OSIIRE REQIIEST <br /> MTNNESOTA Ga DATA PRACTICES ACT <br /> REQIIESTER 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 montns thereafter <br /> unless a dispute or action is pending or additional data -on <br /> you has been collected. <br /> g. You may be required to pay actual costs in making, <br /> certif ying and/or compiling the copies oi information <br /> requested. _ <br /> Date of Request: <br /> � -,� j- � <br /> �� � <br /> � /j�;�.��.� ,� G�C'y <br /> Requester Nam.e: -, <br /> �S J C�' r�ilG�//��'/�y'� ��`��y��c ty: �,i�'%� l�� <br /> Address: �l'' ` <br /> Zip- <br /> Home Phonez Business : <br /> Description of Information Requested: <br /> Reqaester: s Signature: <br /> BELOW INFORMATION TO BE FII.LED IN BY DEPARTMF:NT ONLY <br /> Handled By: <br /> Department- <br /> Request Type: <br /> In person Mai1 Phone <br /> g ested B Subjec� of Data Not Subject of Data <br /> � y' � <br /> Information Requ <br /> ested is Classified: �ublic Private <br /> Confidential Non-�ublic =rotected Non-Public <br /> geqnest is: <br /> Aporoved Denied Approved in Part <br /> Remarks/Commentss <br /> Authorized Signature: <br /> _ $ <br /> Fees: x Total Due <br /> No. of Pages Rate per Page .. <br />