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City of <br /> Pe uot <br /> q <br /> Lakes — - <br /> DATA RELEASE FORM <br /> In accordance with the Minnesota Government Data Practices Act,the City of Pequot <br /> Lakes is required to receive your consent before releasing any information about you that <br /> is classified as private data. Private data is information that is not available to the public. <br /> If appointed to an Advisory Commission or elected as a City Official,I authorize the <br /> City of Pequot Lakes to disclose the following information.You must choose at least <br /> one phone number or e-mail address to be made public. <br /> ❑ Board and Commission <br /> �' Name �Lf��-��,� T, ��1/�r�,► � <br /> ❑ Home Telephone Number <br /> ❑ Home Address <br /> � E-mail address -�'/���ti/��,�7�r,�' 7��I��c�m <br /> ❑ Work Telephone Number <br /> ❑ Cell Phone Number <br /> ❑ Other <br /> Signature: Date: 1/-���a2c'��-r- <br /> This release will be in effect as long as you serve on the Board,Commission, <br /> Council,or Task Force and can be changed upon your request at any time. <br /> C:\Useis�cityhallWppDataU.ocalVvlicrosoft\WindowsUNetCache\Content.0utlook\CPZCH3RJWpplication Form for Boards and Commissions.doc <br /> Page 5 <br />