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► � <br /> • , - _ <br /> � � � <br /> o = � ��� <br /> ��'T'�' of �R <br /> ,� %;:�: ,,,, .i���o� <br /> ' P�o�s�X� <br /> `�`'�,�, ,,'.�``: � . �,� c�.��say,ai;����-���oo� <br /> . j - <br /> ��kEsK�4� <br /> ,� <br /> DAT� PRIVACY A.DVISORY <br /> In accordance �vith `1.5. 1�.0�, Subd. ?. "Riahts oi subjects or data", �ve would lihe to <br /> inform you that your request ior a p�rrnit or license irom the Ciry or O:ono or any oi its <br /> departments may require ��ou to iurnisn cenain priva�e or contidential in:ormation. <br /> You are notiiied tha�: <br /> 1. The info�nation �•ou iurnish «�ill be used to determine ��our qualif cation for the <br /> permit or lice:Lse reQuesced. <br /> �. You may refuse to suppl}� data, but refusal may require that the City der.y the <br /> pernit or �icense. <br /> 3. The information may be shared with other local, state or federal aQencies to t}:e <br /> exter�t necessary to pro::ess �.��. Pe:mit or (icense. <br /> 4, If ��our requested permit or license requires Council action to approve, some <br /> intormation may becam� puolic. <br /> �, You have ce:-:ain ri�hts und�r �I.S. 13.0^ (see follo���in� paaP) to review private <br /> data on yourself. <br /> 6, Your full name is required to process this application or permit. <br /> PLEASE PRL\'T <br /> I.� R R ta r.�i r� F r P N � � � � A F F 1�E �-r' <br /> First �1idd:e Last <br /> ll � � � t�TRN � c <br /> _�ddress <br /> C,I�r.�w. � .�. ..5 S � I l� 4 Z� ' Z�t�t 4 <br /> C it�;' <br /> State Zip thonc <br /> I understand my riahts as stated above. <br /> � , ' <br /> S i Qnarure <br /> � <br /> v TEI.EPHO*!E-4'7�7357• F.AX-�3?3-0510 <br /> r <br /> 1' <br />