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"'�� � � � i <br /> _ _O ,�. ' <br /> �' <br /> O 0 <br /> CI Y of ORONO <br /> ,� `: ' =z�� � �z„►���►otr� <br /> ': ;-"s �, c� Post Offx�e Box 66 <br /> �� ��'�� "- . �'.�r �'~ CC�'StBI BHV��'11IlIlfSOt3�J3Z3�6 <br /> i , ... <br /> ��kESH�4� <br /> DATA PRIVACY VISORY <br /> In accordance with M.S. li.04, Subd. 2, "Ria ts of subjects of data", we would like to <br /> inform you that your request for a permit or licens from the Ciry of Orono or any of its <br /> departments may require you to furnish certain priva or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be us d to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, b�pt re sal may require that the City deny the <br /> pernit or license. <br /> 3. The information may be shared with o er local, state or federal a�encies to the <br /> extent necessary t� process the permit r license. <br /> =�. If your requested permit or license r quires Council action to approve, some <br /> information may become public. <br /> �. You have certain ri�hts under M.S. 13 04 (see followina paQe) to review private <br /> data on vourseli. <br /> (,. Your full name is required to process is application or permit. <br /> PLE?,SE PRP�'T <br /> Sh �'wl M �eha. ��� <br /> First Nliddle Last <br /> IS' s +� s•� � �. <br /> Address j <br /> 1e. ' �� `� - <br /> �5 � - o � <br /> Ciry State Zip Phone <br /> I understand my riahts as stated above. I <br /> � <br /> Sianature <br /> v TELEPHO!VE-473-7357• F. t-a73-0510 <br /> 10 <br />