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ORONO ADMINISTRATIVE OFFICES • <br /> INFORMATION DISCLOSURE REQUEST <br /> • • MINNESOTA GOVERNMENT DATA PRACTICES ACT <br /> REQUESTER NOTE: <br /> A. Request Frequency <br /> • - Private Data on individuals. After you <br /> the <br /> have been supplied the data and informed <br /> ufo ediofsixaits earring,the <br /> data need not be disclosed to y <br /> . .unless :a dispute or action is pending or additional data -on <br /> you .has been collected. <br /> You may be required to pay actual costs in making, <br /> B. certifying' and/or compiling the copies of information <br /> requested. `-'573( 0 / <br /> Date of Request: r <br /> • <br /> • �ieiRequester Name? �WNW, <br /> - � <br /> �,� IP <br /> J( , City: r /��J <br /> Address: <br /> (� 01" ......---c <br /> zip: <br /> Business: • <br /> Rome Phone: <br /> Descr <br /> ./ 'on •f o ation R- ested:. At 1 <br /> ri i d! -/ -� <br /> Requester's Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTM NT ONLY <br /> Handled By: <br /> Department: <br /> Mail Phone <br /> Request Type: In person — <br /> Requested By: _Subject. of Data <br /> Not Subject of Data <br /> Information Requested is Classified: <br /> Public Private <br /> Non-Public <br /> Protected Non-Public <br /> Confidential <br /> Denied Approved in Part <br /> Bequest is: Approved — <br /> Rpm*Larks/Gents: <br /> K_ el _ <br /> ed Signature: ' ; • <br /> Authorized Page ;'' 4, <br /> e,- .... <br /> $ <br /> x Total Due <br /> Fees:. es Rate per Page <br /> No. of Pages . <br /> . ; <br />