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� - <br /> � � " r <br /> -O . O <br /> _- _ c�TYo� oRONo <br /> ,� ';�,'��;�� _ ,�., .t��oe� <br /> \,� ,�:..� .:� , ; � Posc o�ce Box 66 <br /> �•,� ,: 1; , :- �, G cr�sar,�vt,�o�s��� <br /> l ";1. .. . ` � <br /> ��kES8�4 <br /> ��� <br /> __� <br /> DATA PRIVACY ADVISORY <br /> In accordance with �Z.S. 13.04, Subd. 2. "Rivhts of subjects c�r data", we would like to <br /> inform you that your request tor a permit or license from the Ciry or O:ono or any of its <br /> deparcments may require you co rurnish cercain priva�e or confidential information. <br /> You are notified that: <br /> l. The information you furnish «�ill be used to determine your qualification for the <br /> permit or licensz requested. <br /> ?. You may refuse to supply data, but refusal may require that the City der.y the <br /> pernit or license. <br /> 3. The i.*�formation may be shared with other local, state or federal a�encies to tt:e <br /> extent necessary to p:ocess «lz permit or license. <br /> �. If your requested permit or license requires Council action to approve, same <br /> information may becom� puolic. <br /> �. You ha��e ce;�ain ri�hts under M.S. 13.04 (see fo!lo���irta p3aP) to review private <br /> data on yourself. <br /> 6, Your full name is required co process this application or permit. <br /> PLEASE PRL�ri' <br /> / � . /�i'i�% �' <br /> � L � � _ <br /> First �vlidd.e Last <br /> � � � 5����«��' .'r %��'"��/� <br /> rlddress <br /> /� ��,���/ ��-`��� � � ���� <br /> ���,� � �� - <br /> Ciry <br /> State Zip Phone <br /> I understand my riahts as staced above. <br /> .,�_> <br /> � -'� "'~ .-i' <br /> .-' _,,..�- <br /> '�:,--`�� ..-�'�/'y' �:�.---''��„��-_� . <br /> �,f ,,.✓ �� G � � <br /> S ignature <br /> TELEPHO?YE-4'7�7357•FAX-473-0510 <br />