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I <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 er`- Colvv&KIS_5(nri. <br /> ❑ Name <br /> ❑ Home Telephone Number <br /> ElHome Address "1": i <br /> ❑ E-mail Address -001- E54t do.c-O"r <br /> ❑ Work Telephone Number —7.-1c-PD- 5-12f2 <br /> ❑ Cell Phone Number 76 6 9 <br /> -12:2-belc <br /> ❑ Other <br /> Signature: f. • tr _ Date: 12 I C 2 <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:\Mministration\City Clerk\Boards and Commissions\Application Process and Forms\Forms\Application Form for Boards and Commissions.doc <br /> Page 5 <br />