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City of <br /> Pequot <br /> Lakes_ <br /> -- <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 /> Cityaof 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 /> !41 Board and Commission `�,, <br /> IV Name . \(a\'1;J klbV\CLUI <br /> El Home Telephone Number <br /> El Home Address <br /> 1!t E-mail Address ('� <br /> El Work Telephone Number <br /> al Cell Phone Number g/ SJR/-1-7 Itb <br /> ❑ Other <br /> Signature:(- ��, Date: n- 'ty <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\For ms\Application Form for Boards and Commissions.doc <br /> Page 5 <br />