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1 • VI Vi\..Vt,V <br />tEf:I ....,._,, ___ ,_ <br />t. <br />CITY of ORONO <br />MunkJpal Offices <br />Street AddrtH: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />DATA PRIVACY ADVISORY <br />M1lllna lddn11: <br />P.O. Box 66 <br />Crystal Bay, M~ 55323-0066 <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br />to infonn you that your request for a pennit or license from the City of Orono or any of its <br />departments may require you to furnish certain private or confidential infollI1ation. <br />You are notified that: <br />1. The information you furnish will be used to detennine 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 <br />petn:1it 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 page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />Middle <br />Address <br />j/11/1 <br />State <br />I understand my rights as stated above. <br />~Cf.( I Last <br />JJ'Y:Jcf- <br />zip <br />7 Yi cr-(12 <br />Phone <br />S;tlf ,+,-~:.&:U~-c...L..L.:_.,_ _______________ _ <br />DEC-12-1996 09:47 <br />Telephone ('12) 413-7357 • FAX 413-0510 <br />8 <br />6124730510 97% P.14