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� . .. ; <br /> � <br /> Ci��Y O� ����� <br /> b/ Post Office Box 66•Crystal Bay,Minnesota 5a323•Mnnic-ipal Offices <br /> s <br /> s - s � <br /> On the North Shore of Lake Minnetonka <br /> DATA_PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would Iike to inform you that your request for a permit or Zicense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidentia� information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qual.ification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusa� may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other �oca� , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense rec;uires Council action <br /> to approve, some information may become pubiic. <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 required to process <br /> this application or permit. `. � �j • -. � <br /> , � , -- - - ------------- - <br /> - <br /> - - -- --_ -- ----- _- -=-�---- ---- - <br /> -- - <br /> First Middie Last <br /> r.. <br /> , <br /> - j , � -.... . <br /> �. - - ---- - - - - <br /> , -�-----�------ -_.. <br /> Address <br /> � � <br /> �- - _. , <br /> � � . ,. , , . , � ,. , �, . <br /> .._"_.- - �-- ---_'.__------- - - --�----.._. . ._.-- -----�-� --- - ---------�-- <br /> City State Z1p <br /> -- ____.. .... . . <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> 1 <br /> � � � � * ---- -- - ----- <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATTON Fc FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />