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City of <br /> Pe not <br /> Lakes.--z.------- <br /> DATA <br /> 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 /> zr Board and Commission 2 r Z 3�� <br /> S Name 5et2it ' 4"i AA_ t o c <br /> O Home Telephone Number <br /> ❑ Home Address <br /> E-mail Addressrt'��/F'Q-� 9�e ye-t`f�ve,EOM <br /> l' Work Telephone Number 21 g - g 25 - 1576' <br /> ❑ Cell Phone Number <br /> ❑ Other <br /> ' / -7/ ' / <br /> Signature: LY / aie: ylig/ z,_ <br /> This release will be in effect as long as you se e on the Board,Commission, <br /> Council,or Task Force and can be changed upon your request at any time. <br /> S:WdministrationCCity Cledc\Boards and Commissions\Application Process and Forms\Fmms\Application Form for Boards and Commissmns.doc <br /> Page 5 <br />