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City of <br /> Pc not <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 /> El Name Sara Boulka <br /> El Ho Telephone Number 763-656-9074 <br /> El Home Address 3937 Brown Street <br /> El E-mail Address boulkasara©yahoo.com <br /> ❑ Work Telephone Number <br /> ❑ Cell Phone Number <br /> ❑ Other <br /> Signature: Date: 12/17/2021 <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 /> SAAdminisindiordCity ChdABaazdds and CommissionMpplicationPmccsa and ForossWinms1Appliemion Form for Bards and Cam <br /> Page 5 <br />