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. o <br /> � � <br /> o � <br /> cITY o� oRoNo <br /> ,a ,: ``:'.��. � �i���o�� <br /> ;'.' :s � �' Post Office Box 66 <br /> �� � �` ' . `�; ('j~ Crystal Bay,�finnesota 5532.�-0066 <br /> �9kESH�4� <br /> DATA PRIVACY ADVI.SORY <br /> In accordance with M.S. 13.04. Subd. ?, "Riahts of subjects ot data , we would like to <br /> ,� <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require ��ou to furnish certain pri��ate or confidential information. <br /> You are notified that: <br /> l. The information `�ou 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 <br /> re.�nit or license. <br /> 3. The information may be shared with other local, state or federal aaencies to the <br /> extent necessar}� to p:ocess th�. permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> intormation may become pubiic. <br /> 5. You ha��e certain ri�hts under M.S. 13.04 (see follo«-in� page) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�'T <br /> �� ��� �'��� �t : f-' �� �-r;���/� <br /> First N1idd:e Last <br /> ��f i' '� O�?��! y'"'1 r� �= �'/�� `� <br /> Address , L,: - -;' ';�� ,_... <br /> `C �/ <br /> / � r' � y '� �' �'� 7�' <br /> �� �;;,,���,- �y; ; ,� - �<�� �;�fi �, �� , � � <br /> Citv State Zip Phone <br /> I understand my rights as stated above. <br /> ,� <br /> / � / <br /> ---'/ -� �}� t�-� �'�`// `C�12�r7� <br /> < <br /> SiQnature <br /> v TELEPHO!YE-473-7357• F�.Y-�373-0510 <br /> 10 <br />