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� � <br /> ���� �� ����� <br /> � Post Office Box 66•Crystal Bay, :1�tinnesota�a323•Municipal Qffices <br /> e: <br /> � _,s' , �, On the North Shore of Lake Minnetonka <br /> DATA_PRNACY ADVISORY <br /> In accordance with M.S. I5.165 , "Rights of subjects of data", we <br /> would Iike to inform you that your request for a permit or �icense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential. information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or Zicense requires Council action <br /> to approve, some inf ormation may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself . <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> --- ------ -- - -- ----- - ----_ -- - - . _ <br /> -----�-- <br /> Fi st ' ddI ast <br /> �--- -'----.. .. .. ._. __ ._ <br /> _� - -- --- ---- - <br /> Address �� <br /> • . . ..----- --- ----•-- <br /> --- --- --��--�--- - ---�__-� --- -------__ � <br /> City t te Zip <br /> � ����- ----- -- � <br /> Phone • <br /> I un stand my rights �as stated above. <br /> 1 <br /> Signature <br /> BUILDING�ZONING-473-7357 ADMINISTRATION�FINANCE-473-7358 • PUBLIC WORKS-473-7359 - <br /> ASSESSING <br /> � <br /> � <br /> -.,�,.,�..��,•,«:-�r-��.z��:,�-�.a-.�.:-���.-, .."....,:,..,.�•�.�.. ---__ —_— ._.� ..---. _ . <br />