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ORONO ADMINISTR.ATIVE OFFSCES <br /> INFORMATION DISCLOSIIRE RE4IIEST <br /> ��Sp� Ga DATA PR�CTICES ACT <br /> ' gF;QIIESTER NOTE: . <br /> A. Request Frequency - Private Data on individuals. A�te'-" Y°u <br /> have been supplied the data and infor�ed of its meaning, the <br /> data need nat be disclosed to you for six �ontns thereafter <br /> unless a dispute vr ac�ion is pendinq or additional data -on <br /> you has been collected. <br /> B, you may be reauirec to pay actual costs in making, <br /> certifying and/or cont�iling the copies o= in=�r�zti�n <br /> requested. �,�, � `� • <br /> ✓ �,�'r� <br /> Date of Request: � , <br /> ` � �1��� i /��� �, <br /> Requester Nam.es <br /> l / ' � <br /> �� l�7 ���� �� , City: ' <br /> Address: '� �� � �''� " � � <br /> � :��` �� � <br /> zip= ����. � � �� <br /> � � 7 Business: <br /> Hame Phone: %� � <br /> �� ,il�,��� C� ' ��� <br /> Description of Information Reuuested- �" <br /> / <br /> , <br /> Recruester'. s Signature: �� <br /> BELOW SNFORMATION TO BE FII�LED <br /> Y DEPARTMENT ONLY <br /> � ' Ha.ndled By� <br /> Department: <br /> geqaest Type= In person <br /> Mail Phone <br /> Subjec� of Data Not SubjeC� o= Data <br /> g�quested By: _ ` <br /> Tnf'o=m,ation Requ <br /> ested is Classified: ?ublic Private <br /> Nan-?ublic -rotected Non-Public <br /> Contidential _ <br /> Approved Denied ADproved in_Part <br /> gequest is: _ <br /> Remarks/Camme�ts_ <br /> Authorize3 Signat�re: <br /> _ $ <br /> Fees:• X Total Due .. <br /> No. of Pages Rate per Page .. <br />