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.- '�r►;. C��� G--i N �-�S <br /> � � � <br /> O O <br /> � C ITY of OR�NO <br /> ,�, `� J �. J� �tunic�pal ot�ices <br /> :i <br /> �v Post Oftice Box 66 <br /> �'.� `':` G�' crysca►say,�c;anesota ss323-o066 <br /> ��kES�I�4� <br /> DATA PRIVACY ADVISORY <br /> In accordance �;�ith �1.5. 13.04, Subd. 2, "Rights of subjects or data", �;�e would like to <br /> inform you that your request for a permit or license from the City ot 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 informacion ��ou furnish will be used to determine ��our qualification for the <br /> permit or license requested. <br /> ?. You may refuse to supply data, but refusal ma�� require that the City deny the <br /> pernit ar license. <br /> 3. The information may be shared ��ith other local, state or federal aaencies to the <br /> exter�t necessar}• to pr�cess :ri� perrnit or license. <br /> 4. If ��our requested permit or license requires Council action to appro��e, some <br /> intormation may become public. <br /> �, You have cer�ain ri�hts under M.S. 13.04 (see follo�vinR paQe) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this applica�ion or permit. <br /> PLEASE PRIl�TT <br /> r <br /> ' ::�� %� �' � <br /> First Middle Last <br /> /C; , <br /> /�/ ���`� 4� ,� � ���"� <br /> Address i <br /> � � _ . . ,._..; r-� � �4�, ", <br /> / ,, ' � .��;�, C. � ,, �� <br /> C.��n1','�; .�c �r>..- ��; <br /> Ciry � State Zio Phone <br /> I understand my riQhts as stated above. <br /> , <br /> / �� � <br /> SiQn�ture � <br /> '�--�� ' TELEPHONE-473-7357 • E�,X--t73-0�10 <br /> 10 <br />