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ORONO ADMSNSSTR.ATNE OFFSCES � <br /> INFORMATION D7TSCLDA� PR CTICES ACT <br /> • � �4�INESOTA Ga , <br /> • ggQUESTE�Z NOZ`E= . <br /> A, gecruest Frequency - Private Data on individuals. �'��e'-" th� <br /> h�.ve been supolied the data and uf f�esixf�on�se�ereafter � <br /> Qata ne�d not be disc?osed to y <br /> . .�r_�ess .a c3ispute or zc�r..on is �pending or additional data -on <br /> you .has been col.I.ectec. - <br /> you may be reauirec to pay��actual cos�s in uzakinQ. <br /> B. zhe copies or in=oraati-or <br /> certifying and/or co�niling <br /> requested. ' <br /> � _ � �� _ oi , <br /> Date of Request: <br /> � � ��M�S � + ��'��� S��/� <br /> Reqaester Name: . <br /> �ir3cZress: <br /> � �no ��/�-T�i� Tow� d��- City: ;�1A�� � I��I�IN <br /> � Z ip: 5 5 -' �� <br /> SZ- y7 � - � 1 S1 Susiness: <br /> H�e Phone= `� = <br /> Ui�pi�✓� ���i �irs �- <br /> Descr�p�=on of 2nformation Recruested: . a S C I-+ 1P�� 1��R ' <br /> N � V� ���' �� s o� � ,� c� Cl� PP�C�-% . <br /> ReuIIester`. s Signature: . wl-" <br /> BFyOW INgORMATION a-- E FI I BY DEPAR�M-°NT O2TLY <br /> Depar:�ent= C�� 2-- <br /> Handlea. bY= 'v <br /> Mai1 Phone <br /> gequest Type= __�___In Pe'-"son . — — <br /> g�ested By: _Subjec� o= Data <br /> pC Not Sui�j ect of Data <br /> ;n.foraation Requested is Classified: <br /> D� �ublic _Private <br /> �;o�-?ubli.c _=rotected Non-public <br /> Con=idential — - ;n pat <br /> Denied A�proved _- - <br /> gecruest is= C�=APProved — <br /> Remarks/Co�.ents: <br /> Anthorized Signatare: � <br /> _ $ <br /> x Total Due „ <br /> Fees:• e5 R�t� per Fage <br /> No. of Pag . <br />