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3 <br /> ! �--�_\ <br /> / O J■r\ <br /> .�� \\ <br /> �� ` �O <br /> �/ O <br /> �� - CITY of ORONO <br /> I I ,,.� ,�1��,��,;.r z, �+ i,l Municipal O�xes <br /> � � �� till <br /> � �, �;� 's�`f • Post Office Box 66 <br /> .� f��;�:�,�., 7� G'�,� cry�sey,��s�z� <br /> .�. �i ".M'J.'_.��3`G. :/ <br /> s, . <br /> �� 9k�Ko� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would lil:e 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 yau 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 tr�e <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal a�encies to ttie <br /> extent necessary to process �r�z permit or license. <br /> 4. If your requested permit or license requires Council action to approve, same <br /> information may become pualic. <br /> 5. You have certain ri�hts under M.S. 13.04 (see fo�lo�x�ing paQe) 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 /> , , �� <br /> � j <br /> First idd:e Last <br /> , <br /> , <br /> � , � <br /> 4 ` <br /> Address <br /> \ r <br /> i `-�.,/� -� <br /> Cirv State Zip Phone <br /> . ��7�� ���� <br /> I understand m} rights as stated abo�e. / <br /> � <br /> � <br /> L' <br /> /,.. <br /> Sianature <br /> y TELEPHON�—473-7357� F�X-473-0510 <br /> 1� <br />