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Au1•07·Z003 o;:51am Frcm•CITY OF ORONO +9522494616 T-952 P.003/003 F-350 <br />CITY of ORONO r <br />Street Address; <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />MwddpaJ Offices <br />J)ATA PWVACY ADVISORY <br />Malllq Address: <br />P.O. BOl< 66 <br />Crystal Bay, MN 55323·0066 <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 infonnation. <br />You are notified that: <br />1. The infonnation you furnish will be used to determine your qualification for the <br />permit or license requested. <br />·2. You may refuse to supply dat~ but refusal may require that the City deny the permit <br />or license. <br />3. The infonnation may be shared with other local, State or federal agencies to the <br />extent necessary to process the pennit or license. <br />4. If your requested pennit 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 <br />on yourself. <br />6. Your full name is required to process this application or pennit. <br />dl&a/_,_ C <br />First Middle <br />Address <br />.1/7/-709( <br />City State Zip Phone <br />I understand my· rights as stated above. <br />ff(Pe:~~ <br />Signature 7 <br />Telephone {612) 24!:l-4600 • Fax (612) 2494616 9