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► ' '�` ' . , <br /> � ` <br /> � � <br /> O - = � I�ON(� <br /> C�TY of � <br /> � : ; i;:�.`.- _ ,� ,�„n;���ot� <br /> �� i E'y Post Office Boz 66 <br /> �,� ,`.'1•��� :� G'�' Crr�stal Bay,�iinnesota 55323-0066 <br /> , i., <br /> �9kESH�4� <br /> �..:_ <br /> DAT� PRIVACY ADV�LSORY <br /> In accordance «�ith `1.5. 13.Os, Subd. ?. "Rivhts of subjec.s or data", we �vould ii�e to <br /> inform you that your req_uest for a p�rmit or license irom the Ciry or O:ono or any of its <br /> departments may require �Jou co fu.-nish c�rcain private or confidential iniormaiion. <br /> You are notified that: <br /> l. The info�-ination `�ou furnish «�ill be used to determine ��our qualificacion for the <br /> permit or license requested. <br /> 2. You may refuse to suppl�� da�a, but refusal may require *�hat the Ciry der.y tr,e <br /> perrnit or �icense. <br /> ;. The L�formation may be snared «�ith other local, scate or i�deral aQencies to t�:e <br /> extent necessary to process t:�i� pe:rl�t or license. <br /> 4. If ��our :equested pe:mit or license requires Council action to approve. some <br /> intormation mav becom� oublic. <br /> �. You ha��e ce:�ain ri�?:ts under ��I.S. 13.0? (see fo�lo���in� p�a=) to revie�v private <br /> data on ��ourself. <br /> 6. Your fu11 name is reauired to process this application or permit. <br /> I'LE.-�SE PRL�T <br /> ��; � G�� o �' -� � ' �� <br /> First <br /> �r1� d;e Last <br /> �, � �` ��,r. �. �/ � l , <br /> .�ddress <br /> �"���?� ��c� S53 C�� y7�� f��� <br /> Ciry <br /> State Zip Phone <br /> I understand my riQhts as s�ced above. <br /> S i�natu�f <br /> �Pxo�-a-r�-��� • eAx-a�-osio <br />