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CITY of ORONO <br />Street Address: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />Municipal Offices <br />DATA PRIVACY ADVISORY <br />Mailing Address: <br />P.O . Box 66 <br />Crystal Bay, MN 55323-0066 <br />In ai:cordance vvilh M.S. 13.04, Subd. 2, "Rights of subj eels of data", we would like to inform <br />you that your request for a permit or license from the City of Orono or any . L1f its departments may <br />require you to furnish certain private or confidential information. <br />You are notified that: <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />The information you furnish will be used to determine your qualification for lhc <br />permit or license requested. <br />You may refuse to supply data, but refusal may require thal the City deny the permit <br />or license. <br />The information may be shared with other locai, state or federal agencies to the ~ '-(:;£1.;;,; 't <br />extent necessary to process the permit or license. .:0 ~":~.-, <br />If your requested permit or license requires Council action to approve, somr l~ <br />information may become public. \&, (l <br />You have certain rights under M.S. 13.04 (see following page) to review private dat~\ ..:lJ <br />on yourself. \ ~-¢Jf <br />Your full name is required to process this application or permit. <br />' <br />c_he1s+itvL MAu1L JA1-eg w s <br />First Middle Last <br />3 Js o <br />Address <br />J!itv{~toG' /Lo <br />... <br />6&PN o M,A.Jtv ,s=s 3s-1, <br />City / State Zip <br />I understand my rights as stated above . <br />. ea~ <br />Signature <br />Telephone (612) 47'3-7357 • FAX 473-0510 <br />16 <br />Phone