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� o� <br /> o :, o <br /> -�==��� C ITY of 4RON0 <br /> .._a ,, <br /> '` � ����`,t��• � F, Municipal Offices <br /> ��'`� ��.,�' r�`�'f:.� '�, <br /> ,��.��a�.,r�,��J���� <br /> � '�''��=�` SVeet Address: Mailin Address: <br /> � �„` _;;�.°�g g <br /> �C'EggO 2750 Kelley Parkway P.O. Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323-0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br /> to 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 wi11 be used to determine yoi�r 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 infoimation may be shared �vith 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 /> infor�nation may become public. <br /> 5. You have certain rights under NI.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 /> First Middle Last <br /> Address <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> Telephone (612) 473-7357 � FAX 473-0510 <br /> 8 <br />