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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 /> 1) Board and Commission <br /> OKI Name 1)z t ht 1(a.. LLTCCA <br /> ❑ Home Telephone Number <br /> ❑ Home Address <br /> E-mail Address 6-c (4..5tL J U . LifrJuitstom . <br /> co 34,4,_ <br /> if Work Telephone Number 21 E -514$ - S[p 8 <br /> ❑ Cell Phone Number <br /> ❑ Ot r <br /> Signature: Date: 2117 1202- <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 /> SMdministrationTity Clerk\Boards and ComnussionsWpplication Process end Fmms\Forms\Application Form for Boards end Commission doc <br /> Page 5 <br />