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� � �. <br /> � � ;. <br /> aj � � CITY of OROND <br /> 1 4 � <br /> ��� [i <br /> i-1 2 <br /> ` Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • M1� � <br /> � . a ,:�,; On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license f rom the City of Orono or any of its departments may require <br /> you to 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 Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> E. Yaur full name is required to process this applicatian or <br /> permit. <br /> �� � �c��- <br /> First Middle Last <br /> ►��O ��� � �� <br /> Address <br /> � �� n� � s��� <br /> City� State Zip <br /> �� � 1 `-�I� -- <br /> Phone <br /> I understand my rights as stated above. <br /> ��� �ao� . <br /> _ <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING ' <br />