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C�t�►o,�' <br /> �`� ��� <br /> � . <br /> L�����. <br /> DATA RELEASE FURM <br /> In accoxdance with the Minnesota Gavernme�t Data Praetices Act,the City of Fequot <br /> Lakes is required to receive your consent before releasing any infonnation about you t�iat <br /> �°����p�va���a.Private data is infarmation that is not available to the publie. <br /> It'appotinted ta An Adviaocy Camm�ssion or elected as s City Offclal,I aut6orize the <br /> C�y qf Pequot Lakes to disclose t6e followipg informstioa.You must choose at least <br /> one phuue nnmber or e-mall address to be inade public. <br /> ❑ Board and Commission � . �� � d / � <br /> ❑ Name ' <br /> ❑ Home Telephonc Number � ��$' <br /> : ❑ Home Addreas ;��f� �,p �/�� <br /> ❑ E-mai1 Address p . <br /> <.GO� <br /> ❑ Work Telephone Number /� '' �' <br /> ❑ Ce�l Phone Number �.'���„��—� 0,�'� <br /> ❑ Other <br /> � <br /> Signature: Date: /O ''��`oalDo�j� <br /> _ ^.. <br /> Tbis release will be in effe�t as long as you serve on the Board,Commission, <br /> Coua¢il,or Task Force and can 6e changed upon your request at any time. <br /> S:1Adminisl�ationlCity CledtlBoiuds and CommiuionelApplicatiob Pn�cas aad RumulFomis�Application Farm fw�Boa�ds and Commi�'ans.dac <br /> Page 5 <br />