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ORONO ADMSNISTR�TIYE OFFICES <br /> ZIdF'pRMATION DISCLnOS�UREP�Q�=�S ACT <br /> MINNESaTA Ga <br /> REQIIESTER NOTE: - . - <br /> A, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and uffor esixfmonthsethereafter - <br /> data need not be disclosed t� yending or additional data -on <br /> unless a dispute or action is p <br /> you has been collected. <br /> B. you may be required to pay actual costs in making, <br /> certifying and/or coucpiling the copies oi information <br /> requested. � <br /> Date of Requests <br /> � �,� � �� ����_ <br /> ' 2. � S -+- V' C�c � �t�� ��/-t- <br /> Requester Name: <br /> �Z� . � , �,�-2 c�ty: � <br /> Address- <br /> Zip: �JS �� � � �oo �'/ <br /> G � �� � � Business: �� <br /> Home rhonc: � <br /> Descriptioa of Information Requ <br /> ested: �� �� �� <br /> -�a�8� 1 � ��J �� '-� <br /> ���� ��� � ' r/ <br /> Re+quester: s Sign <br /> ature: �'t� 7 <br /> BELOW INFORMATION TO BE FII,LED IN BY DEPARZ'�NT ONL� <br /> Department= <br /> (� �2 Handled By: �` . <br /> e: r� In person MaiZ Phone. <br /> gequest Typ __ — -- <br /> ge�quested By= <br /> Subject of Data � Not Subject of Data <br /> p� aubl1� Private <br /> Tnformation Reqnested is Classifiesi: — <br /> Confidential Non-�ublic =rotected Non-Public <br /> geq�uest is: d- Approve3 Denied Approved in Part <br /> Remarks/Camments: . <br /> . ��,,ti-.— <br /> guthorize3 Signature: �' <br /> Fees:� x $Total Due ._ <br /> No. of Pages Rate per Page <br />