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ORONO ADM=27ISTRATSYE 0�=�S - <br /> INFORMATION DISCLOnS��PR�I�S gCT <br /> • � tiI3�NESOTA GO , <br /> • ggQUESTEFZ NO�E: . <br /> A. gecruest Frequency - P=ivate Data on individuals. �=te'-' �°�o <br /> have been supplied the data and uffo�sixfnon�.:�set'-���reafter � <br /> data ueed not be disclosed t� yendina or additional data -on <br /> � .unless `a dispute or action is �p � <br /> you .has been coll.ected. � <br /> H, you may be reauir�ec to pay ��actual costs in �aking, <br /> certifying and/or compiling zhe co�ies or in�orraatior <br /> requested. Q / • <br /> Date of Requ <br /> est: � r � <br /> r ' <br /> Requester N�e- /J? <br /> /�. c � / city: �-t� <br /> Address: ih J —' <br /> � zz�: � � �Z2/�-. <br /> �� /."� �Z� Busines s: <br /> Horae Phane: <br /> Description of Information Reuuested:. <br /> �w��� � G��� <br /> � gecruester'. s Signature: <br /> BgyOW =LTFORMF,TION TO BE FII,LF.I] IN BY DEPAR �- � OhZY <br /> ��� � '.� Handlea bY= <br /> D ep art�ent= ` <br /> Mail. ?hor e <br /> gequest Type� ✓ In persan . — <br /> Subjec�' of Data �� Not Subjec� o= Data <br /> gequested $y= � — ` <br /> ✓ �ui�Iic Private <br /> �fo�mat�on Requested is Classified: — <br /> Non-?ublic -rotected Non-Public <br /> Con=idential . � <br /> Denied � ADprovec =n_Paz� <br /> geflraest is: ✓ Aporc�ed — � <br /> Re�sarks�Casam.ents- <br /> � �1 � <br /> . . �;�,---� ��:i � ,,,-�-- <br /> Authorize3 Sign.atare: � <br /> = S <br /> Fees:• X Totz� Due __ <br /> No. of Pages Rate per Page <br />