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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 /> ® Board and Commission Li brr rj goarJ <br /> ® Name She-nylon uvhu,Jei' <br /> ❑ Home Telephone Number <br /> ❑ Home Address <br /> ® E-mail Address shall. W hump cowl <br /> ❑ Work Telephone Number <br /> ❑ Cell Phone Number <br /> ❑ Other <br /> Signature: tit) 1/1,(Jak / Date: 3)27122 <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'Admmistratmn'Cay Clerk Boards mid Commis sions.Applicmwn Process and Forms'forms\Applicanon Form fm Boards and Commissions doe <br /> Page 5 <br />