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ORONO ADMSNISTRATIYE �FF=CES � <br /> INFORMATION DISCLOnS��p��I�s �CT <br /> - �TNESOTA GO <br /> • gEQIIESTFK NOTE: . - <br /> g. Request Frecuency - Private Data oa iadividuals. After yau <br /> have been supplied the aata and informed of its meaaing, the <br /> data need not be disclosed to Ye ding or ada t naleda at'an <br /> .unless ��a dispute or ac�ion is �p . <br /> you .has been collected. <br /> g. You may be requir�ed to •pay��actual cos�s in making, <br /> certifying and/or comailing the copies aF information <br /> requested. • <br /> Date of Requests <br /> S �� � <br /> • - i�� , � ,�� <br /> Requester Names ` v ''� � <br /> Aaa=ess: <br /> �z��' .��--�:-�-��1 P� c.� ��ty: <br /> � ZiP: 5`��331 O���- 7��-��-7 <br /> Phane: ��Z, � ��Q� ���' Business: ` <br /> Hcme � <br /> • este3:, l�, C�, wJ <br /> Description of Informatioa Requ ` � <br /> � s � . `� � <br /> � Requester'. s Signature: <br /> BgyOW =NgORMATION TO BE FII,LED IN BY DEPARTME�NT ONLY <br /> Handled By: <br /> Department= <br /> Mail Phone <br /> Ftequest Type� —In Persan . — <br /> g�ested By: _ <br /> Subjec:. of Data Nat Subjec� of Data <br /> Tnfo�ation Requ <br /> ested is Classified: �ub1i� Private <br /> No�-?ublic _==otected Noa-Public <br /> Confidential — � <br /> Denied _ ADproved in_Pa.r't <br /> gequest is: Aporoved __ . <br /> Remarks/Comme�ts: <br /> Anthori.zed Signature: � <br /> = S <br /> Fess:• x Total Due „ <br /> ric. of Pages Rate per Page <br />