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':4 %) 0 Ai <br /> w _ CITY of ORONO <br /> - ,. Municipal Offices <br /> ti. Post Office Box 66 <br /> '� crystal Bay,Minnesota 55323-0066 <br /> kESKDg <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 /> ?. 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 paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRLNT C <br /> e I l'1 - <br /> First <br /> Middle Last <br /> (y- <br /> Address <br /> tAddress <br /> 111 3, -7 -1x,4 <br /> "'' ��{'° �' �`'` Phone <br /> CiState Zip <br /> I understand my rights as stated above. <br /> Signature <br /> TELEPHONE-473-7357 • FAX-473-0510 <br />