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. / . ,,V � <br /> � t <br /> O , . O ��� <br /> G���' o� �R <br /> �a ;;::�. _ �,�, .���o� <br /> r�. • � <<y Post Q�'e Box 66 <br /> �`� , : �'� .� _.- '_�. �~ Cf�'St31 B2Y��IlI1I1F.50t3�J3?3-�6 <br /> ��kESII�4� <br /> �,�� <br /> DAT� PRI'VACI' A.DVISORY <br /> In accordance with �LS. 1�.0�, Subd. �, "Rivhts of subjects or daca". «'e would ii�e to <br /> in�orm ��ou that your request tor a p�rmit or license irom the Ciry of O:ono or any oi its <br /> deoanments may require ��ou to iurnisn cercain pri��a�e or conridential iniormation. <br /> You are notified that: <br /> 1. The informa�ion ��ou furnish will be used to determine ��our qualiiication for the <br /> permit or license requested. <br /> ?. You may refuse to suppl}� data, but rerusal may require that the Ciry der.y the <br /> �ernit or �icense. <br /> ;. The information may be snared «�ith other local, state or i�deral aQencies to the <br /> extent n�cessary to pr�::ess «1� pz;m�t oi license. <br /> :�. If ��our requested permit or license requires Council action to approve, some <br /> iniormation mav becam� puQlic. <br /> �. You ha��� ce::ain ri�hts unde: �'I.S. 13.0? (see fo!lo�vinR paQ=) to revie�v private <br /> data on ��ourself. <br /> �, Your full name is required to process this appiication or permit. <br /> PLE�SE PRL�'T <br /> '�E6 i.v/c 1� G�C� D `�/t'lC� <br /> First �1idd:e Last <br /> / � � � /r�i�✓i✓� 1�i¢t//� �/E � <br /> ��ddress <br /> �T /a�gclG �"''��i/ .5 S�i 4!� ��7�—� "71' � <br /> Cicv Scace Zip Phone <br /> I understand my riQhts as scaced above. <br /> �� , ��� � <br /> Sian e <br /> `" ��xo�rE-sr3-�s�• F�x-.��-osio <br />