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ORONO ADMINISTRATN� ��=�S � <br /> I3`TFORMATION DSSG.LOSURE R.L'4DEST <br /> . �SNNESaTA Ga DATA PR�CTIGES ACT <br /> ' gEQUES�F�Z NOTE: • <br /> A. Recruest Frequency - Private Datinfor�ed1 of itssmeaning, the <br /> ha.ve been supplied the aata and ou for si.x mont:ns thereafter � <br /> data rzeed not be disclosed to y <br /> �unless `a dispute or ac�ion is pending or additional data -on <br /> you .has been collected. <br /> B, you �ay be reauirec to pay actual costs in making, <br /> certif ying and/or compiling the copies o� inf ora.ati.on- <br /> requested. - <br /> Date of Request: � '� �� � <br /> � - '" � /•, ; -, ; <br /> Requester Name- - 0 r l � ( 4 �c . <br /> � City: �' � '���� � <br /> Address: > �� � ( �,� �7 v'� e u ( �� <br /> � � '� � <br /> Z iP: � � `� <br /> gome Phone: Cf � � - �( U � S Business: <br /> Description of Information FZecruested. - C°�t x�r�' � T�x � <br /> j�c c b ���-� �- <br /> �� /C:!�G C % (:_� C L< � i � � <br /> Reuuester`. s Signature: �J �• <br /> BELOW SNFORMATION TO BE FII,I,ID I'•Z BY DEPARTMENT ONLY <br /> Q� 2 HandlecZ BY z <br /> Department: — <br /> oLIn persan <br /> Mai1 Phone <br /> gequest Type= . <br /> gequested By= Subjec� of Data <br /> � Not Sut�ject of Data <br /> �ublic Private <br /> Tn-Formation Requested is Classified: �- — <br /> Non-?ubZi� =ratected Non-Public <br /> Conf idential _ <br /> Q��ipproved Denied Approved in_Part <br /> gequest is: — <br /> Re�.arks/Ca�mests: <br /> An�tb.orize3 Signat�re: <br /> _ $ <br /> Fees:. X Total Due .. <br /> No. of Pages Rate per Page <br />