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S <br /> ' O� <br /> � <br /> � o <br /> : ; ,.�. ,,,,, <br /> C ITY of �RONO <br /> a _ ��,►���,o�� <br /> t' <br /> '' ;r , �' Post Qffice Box 66 <br /> �'� ' '� ' ';�r �J~ Crystal Bay,�linnesota 55323-OOG6 <br /> � - .� - <br /> �kESI304� <br /> DATA PRIVACY ADVISORY <br /> In accordance with �1.5. 13.04, Subd. 2, Riahts of subjects oi data", we would like to <br /> inform you that your request for a pe <br /> rmit or license from the City of Orono or any of its <br /> departments may require 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 qualification for the <br /> permit or license requested. <br /> ?. You may refuse to supply data, but refusal may require that the City deny the <br /> pernit ar license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to process :he permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. You have certain ri�hts under M.S. li.04 (see followina paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�'T <br /> , � <br /> „� <br /> _ ; � i � � �( 1 /'_ <br /> First Middle �Last <br /> I �� 10 �� �'1c�r��� `�� � <br /> Address �—' <br /> � <br /> ���..� � �� ',� �; - ��-_��, �� i-� l�� - �c� � <br /> r� �r� I� � � �. <br /> � State Zip Phone <br /> Ciry <br /> I understand my riQhts as stated above. <br /> � <br /> � ��� �.� <br /> � ;�� ,? �� � / <br /> iQ ature <br /> � TELEPHO!V�-473-7357 � FAX-J73-O510 <br /> 1� <br />