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r <br /> City of <br /> Pequot <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 /> one phone number or e-mail address to be made public. <br /> ❑ Board and Commission <br /> ri Name A471124 4A.1.41.0 <br /> ❑ Home Telephone Number <br /> ❑ Home Address <br /> ❑ E-mail Address <br /> ❑ Work Telephone Number l <br /> a Cell Phone Number (z i ) V i— r14 <br /> ❑ Other <br /> Signature� 2�1 l 1/ Date: /24 / <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 />