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� � �� <br /> , <br /> � �� , <br /> ;�'O O������,. <br /> �i ��_� � � CITY of ORONO <br /> ;�� � ,� �� ' _ �+ �� Vtun;cipal ot�ces <br /> j�?� <br /> 1\1 `�, ��` �. � �� �' Post Of6ce Box 66 <br /> \�� r� �+� .;: i, +.� G'�' Crysta►gay,114innesota 5532.'�0066 <br /> � � � ; . <br /> \\ESHO�% <br /> ��� <br /> DATA PRIVACY ADVLSORY <br /> In accordance with M.S. 13.0-�, Subd. 2, "Rights of subjects or data", we would like to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or conf'idential 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 /> 2. You may refuse to su�ply data, but refusal may require that the City deny the <br /> permit or �icense. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> exter�t necessary to process trc� permit or (icense. <br /> 4. If your requested permit or Iicense requires Council action to approve, some <br /> information may becom� puolic. <br /> j. I'ou have certain ri�hts under M.S. 13.04 (see fo?lo�F�in� paQe) to review privzte <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIN'T <br /> �,� �,t�� � �/ " �,' . � <br /> First � �fiddle La t <br /> �'1'1 � ,; � <br /> Address <br /> �� r�'1.. 5�.'� l�.` N�-I� -��S�� <br /> Ciry State Zip Phone <br /> I understand my riQhts as stated above. <br /> 9 � `J� _. .._ <br /> SiQnature, <br /> TII.EPHONE-473-7357�FAX-473-0510 <br /> 10 <br />