Laserfiche WebLink
CITY OF MOUNDS VIEW g• <br /> INFORMATION DISCLOSURE REQUEST <br /> Minnesota Government Data Practices Act <br /> A. Completed by Requester <br /> REQUESTER NAME:(Last,First,M.): DATE OF REQUEST: <br /> STREET ADDRESS: PHONE NUMBER: <br /> CITY,STATE,ZIP CODE: SIGNATURE: <br /> DESCRIPTION OF THE INFORMATION REQUESTED: <br /> B. Completed by Department <br /> DEPARTMENT NAME: HANDLED BY: <br /> INFORMATION CLASSIFIED AS: ACTION: <br /> 0 PUBLIC O NON-PUBLIC O APPROVED <br /> O PRIVATE Q PROTECTED NON-PUBLIC O APPROVED IN PART(Explain below) <br /> Q CONFIDENTIAL O DENIED(Explain below) <br /> REMARKS OR BASIS FOR DENIAL INCLUDING STATUTE SECTION: <br /> PHOTOCOPYING CHARGES: IDENTITY VERIFIED FOR PRIVATE INFORMATION: <br /> O IDENTIFICATION:Driver's License,State ID,Etc. <br /> 0 NONE O COMPARISON WITH SIGNATURE ON FILE <br /> Pages x c= El PERSONAL KNOWLEDGE <br /> O SPECIAL RATE: (attach explanation) O OTHER: <br /> AUTHORIZED SIGNATURE: DATE: <br /> C:\ADMIN\NOTICES\DATA-PRI.FRM <br />