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Y <br /> � <br /> +� ' , � <br /> , --_� <br /> � � � <br /> � _ - � ON� <br /> �i�Y of OR <br /> ,� %;:;�..- _ ,>., .t��o�� <br /> .� �� l cti Posc Qt�ce sox 66 <br /> `�,� ,`� 'ti � - ��' Cnstal Bay,�tinnesota�5323-0066 <br /> '.�,. <br /> ?.. :- _ <br /> �9kESH��� <br /> ,,��:=� <br /> DAT� PRI V�CI' ADVLSORY <br /> In accordance with �I.S. 13.0?. Subd. ?, "Ri�hts of subjects or daca", we would like to <br /> inform you that your request ror a p�rr.iit or license from the City oi Orono or any of its <br /> departments may require ��ou to rurnisn c�rtain pri��a�e or confidential information. <br /> You are notified that: <br /> 1. The inforrria�ion ��ou iurnisn «'ill be used to determine }�our qual:itcation for the <br /> permit or license requested. <br /> 2, You ma�� refuse to suppl}� daca, but refusal may reauire tnat the Ciry der.y the <br /> per�nit or Iicense. <br /> 3. The informacion may be snared �vith other local, state or federal aaencies to t?-:e <br /> extent necessar}� to process �:� Pe:mit or licer.se. <br /> =�. If �our requested permit or license requires Council ac:ion to approve. sorrie <br /> inrormation mav becom� pubiic. <br /> �, You ha�e ce:�ain ri�rts unde: �I.S. 13.0? (see follo�vin; paQP) to revie�v private <br /> data on yourszlf. <br /> (, Your iu11 name is reauired to process this application or permit. <br /> PLE�SE PRL�'T <br /> �iA�1Q I C� c1`A Iy1 P�S twi�►l S � <br /> First `�i�adle Last <br /> 3 � ' <br /> 7�� <br /> .�ddress <br /> � N , ss 3�� - ��7a -(�5 33 <br /> Clry <br /> Scate Zio Phone <br /> I understand my riQhts as s�ced above. <br /> ��W. <br /> ignature e-�- <br /> �r��o*+E-s�rs-r�s�• FAx-a�-osio <br />