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.� � <br /> Ctt�► 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 /> . __ _ _ - -- _ ___ <br /> one phone number or e-mail address to be made public. <br /> ,(�� ,� ` �9 <br /> � Board and Commission '�` S �' C� ln� Wt t�,5 l b/.l <br /> ❑ Name �1 e V l� ���/�1/�.�C�t� <br /> ❑ Home Telephone Number <br /> � , . <br /> ❑ Home Address �� �d ��� <br /> E-mail Address cin:T � �D�� ��C-��1�''� <br /> � <br /> ❑ Work Telephone Number <br /> � Cell Phone Number a�� " �j � �`� ��'b 3 <br /> ❑ Other - <br /> l,--�""` <br /> .. _ <br /> �/ � <br /> Signatur ate• � �� <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:Wdministration\City Clerk�Boards and Commissions�Application Process and Forms�Fortns�Applica6on Form for Boards and Commissions.doc <br /> Page 5 <br />