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C ITY of ORONO <br /> ti <br /> Post Office Box 66 <br /> 55323-0066 <br /> �kESIID4- <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd "Rights <br /> fromsubjects <br /> CiryrotatOrono oroanylof o <br /> inform you that your request for a perm or license <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish willbe used to determine your qualification for the <br /> permit or license requested. <br /> . You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal agencies toj the <br /> extent necessary to process the permit or license. <br /> uested permit or license requires Council action to approve, s�me <br /> 4. If our req <br /> information may become public. <br /> 5. You have ce,,ain rights under M.S. 13.04 (see following page)) to review prvate <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> I <br /> PLEASE PRLNT <br /> • e ��Lf £/rr+cr �n <br /> First Middle Last <br /> I <br /> * A- + —�— <br /> Address <br /> G$a� <br /> City State Zip Phone <br /> I <br /> I understand my rights as stated above. <br /> Signature <br /> TELEPHONE-473-7357 • FAX-473-0510 <br />