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! <br /> y, � <br /> r <br /> CZty 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 /> _ <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 /> � � <br /> � Name <br /> ❑ Home Telephone Number <br /> � Home Address <br /> � E-mail Address <br /> ❑ Work Telephone Number <br /> � Cell Phone Number <br /> ❑ Other <br /> Signature• _ � �y. � Date• E D �Z 3 —Z� <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 /> S:�Administration\City Clerk�Boards and Commissions�Application Process and Forms�Forms�Application Form for Boards and Commissions.doc <br /> Page 5 <br />