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ORONO ADMSNIS�RATIV� OFFI�S <br /> =NFOgMATION DISCLOSURE R�Q�ST <br /> �INNESa2A � DATp, PRACTSCES ACT <br /> �Q�S� N��� � - Private Data on individuals. After you <br /> A, Request Frequenc� <br /> t e <br /> have been supolied the data and ouf fQ esi�f�on�sethereafter <br /> data need not be disclosed to y <br /> unless a dispute or action is pending or additional data -on <br /> you has been coll.ected. ��tual costs in making, <br /> g, you may be required to P�Y �re copies o= in�ormation <br /> certirying and/or corr�piling <br /> requested. � <br /> � <br /> Date of Request: - �� <br /> � � <br /> �/� <br /> : - ��� - .?�.I-�� Li �-''L <br /> Requester N�e= � ,�� <br /> CitY: L��'✓/�'�% <br /> Add=e s s: / �L'--,S" ��� 1/'� l��� <br /> /—� <br /> zip: �' � y � p. _ `i �, <br /> C�I1 _ J7.SS'� Business: �2l ' 7 <br /> gome Phone: � <br /> Description � Information FZequested: <br /> �� � ' `� ��i�� <br /> ���;�j%�� �c�'�'1 �7� �, � �%C <br /> �_ _ <br /> �� ,,� �� �i� / <br /> , � ' � � ;_ <br /> ' C ,,;�� , � �� ..� � <br /> ':!. <br /> Re�uuester` s Signature= ` <br /> BgyaW INgOgM-�TION TO BE �I�L�D IN BY DEPAR�NT ON�Y <br /> r� <br /> -. --� Ha.ndled By: c''�:s <br /> i S-� �� +_ <br /> Depart�n�t= <br /> $equest Type: �� In person <br /> Mai? phone <br /> Requested By: — <br /> Subjec� or" Data ✓� Not Su'r�jec� of Data <br /> Tnfozmation Reqaested is Classified: � <br /> �u�Iic Private <br /> Non-?ub1;c =rotected Non-PuDlic <br /> Considential — <br /> Denied A�oroved in Pat'� <br /> ge�quest is: Approved - <br /> Remar3�cs/Co��ts: <br /> n� <br /> � <br /> Si ature: `�'�, ,,�,�-�_- - <br /> Autharize� 9n <br /> .. _ $ <br /> X Total Due <br /> Fees: g Rate per Page �' <br /> No. o= Pa es <br />