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ORONO ADMSNISTR.ATIYE ��=�S ' <br /> �TFORMATION D2SCLOSURE RESZ�ST <br /> • � �iI�INESOTA GO DATA PR�CTICES ACT , <br /> • gEQ17ES� NOZ`E- . <br /> A, gequest Frequenc� - Private Data on individuals. �te= �°�u� <br /> h�.�-e been supolied the aata and ouf fQ esixfnon'�r.'nsethereafter � <br /> datz. ne�d not be disclosed to y <br /> . .unless :�a dispute or ac:.ion is �pending or additional data -on <br /> you .ha.s bee� col.lected. � <br /> you may be reauired to pay ��a�tuzl cos�s in �akinQ� <br /> B. zhe cooies or inforaatior_ <br /> certifying and/or co�piling <br /> requested. `//�� D • <br /> � � <br /> Date of Req�est: <br /> • • �C/ <br /> i � <br /> ReQuuester Name= ' �����`J <br /> - �,-, � , City: <br /> p.r3dress- C� ` <br /> � Z i�: � <br /> Business: <br /> H�.e Phane: � � j <br /> Descr � on f o ation R _ <br /> ested: '"�'� <br /> ,% / J - <br /> � Re�su.es�er'. s Signature: <br /> BgyOW =NFORMATION TO BE FII.�I�E� IN BY DEPAR�'�� O�Y <br /> Hancclea sy: <br /> Depar;"�.ent: <br /> Mail Phone <br /> gequest Type- —sn person . — — <br /> ge�zes�ed $Y= — <br /> Subjec� o= Data Not Subjec� o= Dz�� <br /> =�o�at; on gequested is Classified= <br /> �u:olic _Private <br /> Conf idential <br /> Na�-?ubli.c ,="rotected Non-Public <br /> — P_�nroved irs Part <br /> Aooroved Denied -- <br /> gecruest is: _ — <br /> Re�ar�s�Comments: <br /> ` �7 /. <br /> � <br /> - . G j�'� �' '�,.. �, -;:�� <br /> Anthorized Signatare: `� '� ,; . <br /> .i� � _ $ <br /> Fees:• X ' Tota1 Due _, <br /> No. of Pages Rate per Faqe <br /> . { <br />