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. , �� <br /> �- � � � ���'� o� ��.��.�aT� <br /> `I 11 <br /> Post Office Box 66•Cr5'stal Bay,Minaesota 5�323•Municipal Offices <br /> � _ <br /> � - � � � <br /> On the IVorth Shore of Lake Minneton a <br /> DATA PRS�ACY ��SORY <br /> "Ri hts of subjects of <br /> 9 Y <br /> 2n accordance with M.S. 13• ou'thatdyour request for a P=quire <br /> data" , we wou3.d like to inform y of its depar��ents may <br /> ;�.cense from the City o= Orono or anY � � n=o�ation. <br /> you to furnish certain private or confident_al <br /> �ou are notified tnat: <br /> T w�IZ be used to dete'-"mine your <br /> 1. m�e inTormation you fu_nisn <br /> cuali�icat'on for the perni� or license requested- <br /> 2. You may reruse to supply <br /> data, but re=usa1 may require that <br /> the City deny the pe�i� ar license. <br /> be snared witn otZer Iocal , s�a�e er <br /> 3 . The information may o roc�ss the pe'-"mi� ci <br /> f ederal agencies to the extent nec�ssary to P y <br /> license. , <br /> yo pe�ait or IiC8RS2 reauyTes Counc�I. a��=or <br /> a. �f your recues`..d � become public. <br /> to approve, some in=ormat.�on �ay <br /> 5 . You have certain rights under M.S. 13.Oa to review griva�e <br /> data on yourself. <br /> 6 . Your fulZ name is recuired to procsss this application or <br /> pe�it. <br /> %� �� f-E�v r/v <br /> �� i c �_ �� Las� <br /> � <br /> Middle <br /> r^irs� <br /> ` �-��. �- � � ��� _, � � t- i �� � <br /> � <br /> Address / / <br /> l �1. J� j Cc�� <br /> �( ) , I� <br /> /`lC'�� i4 � �� Z1.D <br /> ' State <br /> Ci�y <br /> C/ �,'/ - %/ -�-� — <br /> Phone <br /> I understand my rights as stated above. <br /> : �/ / �` _ - - -- <br /> j� -�"` � . <br /> Signature <br /> 3UILDtNC&ZONING-473-7357 • ADMINiSTRATION&FIN.�NCE-;73-7358 <br /> • PUBLIC WORKS-473-7359 <br /> �SSESSING <br />