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Ci ty of <br /> �'e Uc�� <br /> q <br /> L�.l�es . <br /> DA►TA RELEASE FQRM <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 infortnation 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 �f' �2- �GO n�D:��c �� �j'(.� <br /> ❑ Name <br /> ❑ Home Telephone Number � � ��-C�S�"6�ZO <br /> ❑ Hame Address , ?i��y ( P)� �� �./J_�p ��'2 <br /> � <br /> ❑ E-mail Address � �-O Go� �Qsy►� a r . L d N'� <br /> ❑ Work Telephone Number ' �.�f`�SZa' <br /> ❑ Cell Phone Number �j�+ �'t-F <br /> ❑ Other <br /> � <br /> Signature: ' Date: /� �'S <br /> This rel�asQ will be in effect as long as you serve on the Board,Commission, <br /> Council, or Task Force and can be changed upon your reques#at any time. <br /> S:�tldmmi��atiun�ity C1erk�Bunrds aml Commission�\Application Prur.ess and Forms�Focros�Applicatiun Form for Boards and Commi�sions.duc <br /> Page 5 <br />