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O O <br /> 4, 0 k <br /> CITY of ORONO <br /> Municipal Offices <br /> •' A Post Office Box 66 <br /> A�r Crystal Bay,Minnesota 55323-0066 <br /> i. `` <br /> 9kESI104 <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 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 /> 2. 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 permit. <br /> PLEASE PRDIT I <br /> g ict� C4142C41 ies L.,A-U/eA'c <br /> First Middle Last <br /> criS k)irl c�tt c v'S'T T/2-4=}r <br /> Address <br /> of Duty /'Yl jt) S5364 7�-� I <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> TELEPHONE-473-7357 • FAX-473-0510 <br /> 10 <br />