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ORONO ADMSNISTRATIYE OFF2CES <br /> 2?�IFORM�TION DISGLOSURE RE4IIEST '� <br /> IiZNNESOTA Ga DATA PR�ICTICES ACT `'�� �P <br /> . , . ' ����� <br /> ' gEQIIESTER NOTE: <br /> A, Request Frequency - Private Data on individual.s. After yocf�. <br /> have been suppl.ied the data and inforuted of its meaning, <br /> the <br /> data need 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 coll.ected. <br /> B, you may be reQuired to pay actual costs in making, <br /> certifying and/or coutpiling the copies o= iniormation <br /> requested. � <br /> Date of Request: �� � �� � � <br /> � �, �/ -� � �/5�/ <br /> Requester Name: - � � . <br /> �j�� 'j �; �City: <br /> Address: <br /> Zip: �5�� � �: _ <br /> Hcrme Phone s � �� �- ���� Busines s: <br /> escription of I ormat'on Reuuested: <br /> �����.� <br /> � ��� � � � <br /> � �� <br /> Requester: s Signature: <br /> BELOW INFORMATION BE FII�LED IN BY DEPARTMENT ONLY <br /> Handled Bys �,v� <br /> Department: �� G <br /> Request Typez ;� In person Mai1 <br /> Phone <br /> gequested By= Subjec� o= Data � <br /> Not Sub7ect of Data <br /> .�� ?ublic Private <br /> Inform,ation Requested is Classified: — <br /> Confidential Non-?ublic =rotected Non-Public <br /> „�' Approved Denied Anproved in_Part <br /> ge�uest is: — <br /> Remarks/Co�aents: <br /> Authorized Sigaature: 1 <br /> � _ $ <br /> Fees:• x Total Due <br /> No. of Pages Rate per Page <br />