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ORONO ADMINISTRATIVE OFFICES <br /> INFOI2MATION DISGLOSIIRE REQIIEST <br /> MINNESOTA GOVERI�Il�SIdT DATA PRACTICES ACT <br /> gEQDESTER NOTE: � . . . <br /> p,, Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and infornted of its meaning, 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 collected. <br /> g. You may be required to pay actual costs in making, <br /> certifying and/or compiling the copies of information <br /> requested. . <br /> Date of Request: Z <br /> �l. <br /> Requester Name: - � <br /> Address: � Z 3 e•v•� City: �1P4� <br /> Zip: .�.�y// <br /> Home Phone- .S�z-�- -L� �" Business: �A�� <br /> Description of Information Requested: i ' �� � U <br /> �� � L� �w ��ct�cw <br /> Regnester'. s Signature: <br /> BELOW INFORMATION TO BE IN DEPARZ'MENT ONLY <br /> Department: Han.dled By: <br /> Request Type: In person Mail Phone. <br /> R ested B Subject of Data Not Subject of Data <br /> equ Y= <br /> Information Requested is Classified: <br /> Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Reqnest is: Approved Denied Approved in Part <br /> Re�arks/Co�mments: <br /> Authorized Signature: <br /> Fees:� X $Total Due <br /> No. of Pages Rate per page •- <br />