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� <br /> �a <br /> 1 <br /> � O� \ <br /> O • O\\ <br /> -�=�:���- � �� CITY of ORONO <br /> � A�+����r��1 �i� Municipal0[6ces <br /> t' ��� .-��' � Past OS1ce Box 66 <br /> � I �',a:.::�,'� I Crystai BaY,MToonc�ota 5532.'i�0066 <br /> fK:���:i;;��� 1r G � <br /> Z � <br /> 9� ;'��y'o4�' <br /> ESI3 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, Rights of subjects of data", we would like 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 certam private or confidential information. <br /> You are notified that: <br /> 1. The information you fumish 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 Ciry deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> exter�t necessary to p:ocess the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become punlic. <br /> 5, I�ou have cer�ain ri�hts under M.S. 13.04 (see fo!lowing p3ae) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> �ge�fi �s�ri� �'i i��t Gs'iI� <br /> First Middle Last <br /> 2 2 6 7 S` /,��Gcc��S � cSl <br /> Address <br /> � <br /> / Y/l�c�o Ql� /�'i /� ��J 3 / ���r �� 3� <br /> Ciry State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> �otvE-a�-r�•F�►x-a�-osio <br /> 10 <br />