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ink <br /> /100 47. <br /> /,.. <br /> v O <br /> ,, 1, CITYofORONO <br /> r . ,, 'i <br /> Al Municipal Offices <br /> ,NAG Street Address: Mailing Address: <br /> '�Es8p�' 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 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 permit <br /> 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 /> , <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 data t -5 <br /> on yourself <br /> ' <br /> 6. Your full name is required to process this application or permit. <br /> kiiiteSc D �2wd( ,,. <br /> x.� C <br /> First Middle Last; <br /> vi ciS - UJA46-401-rk fte ) iskjo <br /> Address A <br /> 41 SIZZ .ia <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> (ignatur <br /> Telephone(612)249-4600 • Fax(612)249-4616 9 <br />