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ORONO ADMSNISTRATNE OFFSCES <br /> INFORMATION DISCLOnS��P���S ACT <br /> �S27NESOTA GO . - <br /> �Q�S� N� - Private Data on individuals. After you <br /> A, Request Frequency <br /> have been supplied the data and informed of its meaning, t e <br /> data ne�d not be disclosed to you for six months thereafter - <br /> � unless a dispute or action is pending or additional data -on <br /> you has been collected. <br /> B, you inay be required to pay actual costs in making, <br /> certif ying and/or compiling the copies oi inf ormation <br /> requested. � <br /> Date of Request: � � <br /> � ��1 ����_ <br /> gequester Name: 2. � S \l��� ��� �j/� <br /> ) Z� , '��,(1,�, � �,� city: <br /> pyddress• (� <br /> Zi S S �31 � <br /> p- �c�� D� �/ <br /> G�� ��- l� f l� Business: <br /> gome Phone: - <br /> � ested: �� �� �� <br /> Descriptian of Information Re�qu <br /> �-a�g� � � �3 �� <br /> a ��J �� r( <br /> Requester: s Sign <br /> ature: �'�v 7 <br /> BELOW INFORM�TION TO BE FII�LED IN BY DEPARTI�E?NT OPTL� <br /> (� �2 Haadled By: d ` ' <br /> Depart�ent= <br /> Mail. Phone. <br /> gequest Type= 0` In person — <br /> Subject vf Data � Nvt Subject of Data <br /> Requested By= — — <br /> Tnformation ge�qaested is Classified: <br /> � ��Ii� private <br /> Noa-Public =rotected Non-Public <br /> Confidential _ <br /> gequest is: d-Approved Denied Approned in Part <br /> — <br /> Remarks/Coa�ments: • <br /> � ���.N— <br /> Authorized Sigaature: �' <br /> _ $ <br /> Fess:• x Total Due ._ <br /> No, of Pages Rate per Page <br />