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� � =-_ _ <br /> � 0 �T <br /> � ' V <br /> O O <br /> CITY of ORONO <br /> r� �1; 'l,:�.• �'+ i�funicipal Offices <br /> �;, ,j, � �, Post Office Box 66 <br /> �'C� " ' �y' ' :`!,�r �j~ Crystai Bay,biinnesota 55323-OOG6 <br /> � •.7 �: � <br /> 9kESH�4 <br /> �____ <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information ma_y be shared with other local, state or federal a�encies to the <br /> extent necessary to process the permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> inf'ormation may becom� punlic. <br /> 5. You ha��e certain riRhts under M.S. 13.04 lsee following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> ��'1"I�I�:�� �I�2�J�5 Cti��LS 1� <br /> First Nliddle Last <br /> ( � D �F'S� �c� i�,� �c� - <br /> Address <br /> l_1� CC%/ii (� �1 �� . .�-.��. �C �-� r,� �� - l�7� -�S 3,� <br /> Cirv State Zip Phone <br /> I understand my ri�hts as stated above. <br /> � . �Y !�.�����"`"�-- <br /> . � <br /> Si�nature <br /> � TELEPfIO?YE-473-7357• F.�ti-473-0510 <br /> 10 <br />