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: � �� . <br /> � ��� <br /> ,,�o o ,�, <br /> �; - --f ; _ �,�� CITY of �RONO <br /> i�� ����'��� - - �' <br /> � .j��•r� ,yy 'r hiunicipal Offices <br /> 1� �y ' Post OH'xe Box 66 <br /> \\�� ��� �! '.����' '�4 G1� Crystal Bay,:�Sinnesota�53Z�0066 <br /> ,�i, �� <br /> \� � �•f•.\��+ � , <br /> \ ��E���/,. <br /> DATA PRIVACY ADVISORY <br /> In accordance �vith M.S. 13.04, Subd. 2, "RiQhts of subjects or data", we would like to <br /> inform you that your request for a permit or license from the Cirv of Orono or any of its <br /> departments may require you to furnish certain private or co�dential information. <br /> You are notified that: <br /> l. The information you 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 the <br /> �ermit or license. <br /> 3. The information may be shared with other local, state or federal aQencies to the <br /> extent necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> j. You have cenain ri�hts under M.S. 13.04 (see following paae) 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 /> —� � <br /> �� � � �-� <br /> � �� � <br /> E_«-� <br /> First Nfiddle �SL <br /> �.L C�� �'���� < � ��,' i� j <br /> Address <br /> � ;�� j� ` 1:�7 ._ � 1�(' <br /> ' Phone <br /> Cirv State Zip <br /> I understand my riQhts as stated above. <br /> --, � �� <br /> � <br /> � �- �-r <br /> / � �—'. <br /> ianature <br /> v TELEPHO VE-473-7357• F.a.�C-473-0510 <br /> 10 <br />