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� <br /> Ci�j► 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�'equot Lakes to disclose the following information.You musf choose at least <br /> one phone number or e-mail address to be made public. <br /> � Board and Commission <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: Date: �'D-'l/-�0�('� <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 CommissionsWpplication Process and Forms�Forms�Applica6on Form for Boards and Commissions.doc <br /> Page 5 <br />