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ORONO ADMINISTR�TI� ��ICES <br /> INFpRMATION DISC.LOnA�EP���S ACT <br /> MSNNESOTA GO . <br /> ggQIIESTER N��- - Private Data on individuals. �fte� tne <br /> p,, Request Frequency <br /> have been supolied the data ana" Quf fo esix montnsethereafter <br /> data need not be discZosed tfl y <br /> ute or action is pending or additional data -on <br /> unless a disp . <br /> you has been coZlected. costs in making, <br /> v be requireci to pay actual <br /> B. ou may t:e copies o= inr"ormatior. <br /> certifying ar_d/or compiling <br /> requested• � <br /> Date of Re�uests 1 � S . <br /> ;. , <br /> ' ; , I�f�t' .��.L L�---� ,� <br /> ester Name= `� " "�" �'� <br /> Requ - � � City: �� L�_.t� f <br /> Addr e s s: ,'��`��/ �-' ' <br /> zip= �� 3 �� <br /> - c Business : � 7�, _`��'��G <br /> H�e Phone: r �� — <br /> o�a�on gecruested: <br /> Description of � � 4/,c� . <br /> r �� <br /> � � �� > �- C��, ., <br /> / � <br /> � ����� L r7L�+ — <br /> �C�CSter` s Signature: � <br /> BgyOW �NFORMATION TO BE FII,L�D IN BY DEPART��T O�'Y <br /> n - .� Hasdle�d By: <br /> �• � . <br /> D e artm�t= 'i� <br /> � � Phone <br /> Mai_. — <br /> Request Type= i'` In persen — <br /> Recruested BY: —Sub j ec� <br /> of Data � Not Subje�� of Data <br /> ���I�� _Private <br /> Tnfo�mation Reques�ted is Classified: <br /> Non-�ubl=� =rotected Nan-puDZic <br /> Confidential — <br /> Denied A�proved in par� <br /> R�eS.� is: �C_Aporoved — _ <br /> Re�ar3�cs/Cauffients- <br /> Authorize3 Signat�re: <br /> � _ $ <br /> X Total Due <br /> Fe�s: es Rate per Page .. <br /> No. of Pag <br />