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City of <br /> Pequ <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 /> jBoard and Commission <br /> ❑ Name /�/ �t j a- <br /> ❑ Home Telephone Number /� <br /> El Home Address cps 7/? Rd /07 ? I5 <br /> ❑ E-mail Address <br /> ❑ Work Telephone Number <br /> ❑ Cell Phone Number � 1,0 <br /> ❑ Other <br /> Signature: . , % Date: ? 3 <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:1Admwstration fty Cle*Boards and Commissions\Appiicarion Process and Forms1Forms1Applicatiam Form for Boards and Commissions.doc <br /> Page 5 <br />