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c 0 <br /> CITY of ORONO <br /> �., Municipal Ota <br /> ', ;:" ,1$' 'il Post Office Box 66 <br /> � ,` _ • <br /> Crystal Bay,Minnesota 55323-0066 <br /> kESSOVv. <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04. Subd "Rights <br /> fromsubjects <br /> the Cityrof ta". we Orono oranylike to <br /> inform you that your request for a permitor license <br /> of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be 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 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 /> 5. You have certain rights under M.S. 13.04 (see following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or peiiilit. <br /> PLEASE PRLNT <br /> b��fi_iA Middle Last <br /> First <br /> Address <br /> 4 D MC MN <br /> Phone <br /> City State Zip <br /> I understand my rights as stated above. <br /> Signature <br /> TELEPHONE-473-7357 • FAX-473-0510 <br />