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_ .. ��l <br /> �I7�Y of UROl\T� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323�Municipal Offices <br /> � 0• <br /> � On the North Shore of Lake Minnetonka <br /> � o - � A <br /> � <br /> � DATA PRIVACY ADVISORY <br /> � -- - - - - <br /> � In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> ! would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> ' furnish certain private or confidential information. <br /> ' You are notified that: <br /> 1. The information you furnish will be used to� determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other �ocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are reguired to process <br /> this application or permit. <br /> � 1 �(�0�.� - ---- •--- "g..__'_' <br /> -' - ---- - -- -- - ---- <br /> - ---- • ---•-------_._._ ._. <br /> First Middle Last <br /> �,3,� ��r o �a--v� � � ^s a" - ----- _. .. ._ . ._ .- <br /> Address <br /> � <br /> �-��- �n ��-� J <br /> - ---�-- <br /> ._.. .. .._ ---- _�---- _ ----- --•-••-._. ___� �- -- __ ..------------- ----- -...- ---�--•- - <br /> City State Zip <br /> `-� � � �' 7 7� --- - - --- <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> � <br /> Signature <br /> - _ _ . _ . . . _ - - <br /> BUILDING&ZONING—473-7357 � ADMINISTRAT'ION&FINANCE—473-7358 • PUBLIC WORKS—473•7359__`__ <br /> A3SESSING <br />