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� <br /> % � � <br /> T' � <br /> O - O � <br /> --- _ cITYo� o�oN <br /> �, : �; �_.- _ �+ `t„��to� <br /> ,_; , <br /> � � , , Post o�ce soz 66 <br /> ':�'.�, ,' •;�: 't;- ��, p� crv��y,��o�s3�-oo� <br /> ��kESH��� <br /> �� <br /> �%' <br /> DATA PRIVACY ADVLSORY <br /> In accordance �vith ��1.S. 13b�, Subdor licensetfroms the Ciryrot�tO:ono or�ana lo e o <br /> i n f o r m y o u t h a t y o u r r e q u e s t r o r a p e r m i <br /> departments may require �rou co iurnisn certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish «�il! be used to determine ;�our 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 /> permit or �icense. <br /> 3. The information may be shared with o[her local, state or federal a�encies to th.e <br /> exter,t necessary to g:o��ss ���� permit or license. <br /> :�. If your requested permit or license requires Council action to approve. some <br /> information may bec�m� puolic. <br /> �. You have cerain ri�hts under M.S. 13.04 (see fo?lo<<�in� paQ�) to review private <br /> data on yourszlf. <br /> 6, Your full name is required to process this application or permit• <br /> PLEASE PRL�T'r' <br /> LF� ;�/l �k � �? �2 <br /> C" ��� � �iidd:e Last <br /> First <br /> 2 �-�, �J`bi�-t �-u-S� � L �`� <br /> �ddress <br /> r �` ' 4 O � — Z.'� cU � <br /> �� � �� �� ,�, � � � �s b <br /> Ciry <br /> State Zip Phone <br /> I understand my riQhts as stated above. <br /> `l.J''��'l� <br /> S i�nature <br /> �.�xorrE-a�-�s�•Fax-ar�-osio <br />