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� <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneeota 55323•Municipal Offices <br /> • <br /> • . � o On the North Shore of Lake Minnetonka <br /> D�l�� �.'R�V�CY �V��QR�L <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> �% � � �c ��_�-----. <br /> _ _ _.___ _ <br /> _. _--------- ---.-----.-- ---.----_ . .___._._._ __ . -- - ._._._._. <br /> First Middle Last <br /> __ 2.�...��!�_.. ___...__� _.. ... _ .�-e___ ..._._��.� •--�--•... - --. ...... ._.._----. _._.. ... .- -- <br /> Address <br /> �-�.� -S� �� 1 <br /> � _---- --._ _.___ ..._._.._. ..___. ---._._...- -------.. -------.---.____._ <br /> City State Zip <br /> , <br /> __ ._._. .��3 �--.�s�_..�.__�_. ------.�------ <br /> Phone • <br /> I understand my rights as stated above. <br /> � <br /> Signature~ <br /> BUILDIIVG k ZONING—473-7357 • ADMIIVISTRATION dt FINANCE-4734358 � PUBLIC WORKS-4�3-7359 _ <br /> _ A3SESSING . <br />