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/���-_ <br /> I O� <br /> ��O . O . <br /> �' -�� C ITY of ORONO <br /> 'I'1I��1 aj �1�3�',��t r�v j Municipal Offices <br /> \� �� ���t ��� F+ �-� Post OfFice Box 66 <br /> � �'����i�:�:��.•t���r �J�';� Crystal Bay,Mimiesota 5532i-0066 <br /> � ,� , ,";r•�,...:g,� <br /> ,�9.k-E p <br /> �,��5�,,-. <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to <br /> inform you that your request for a permit or license from the Giry 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 ycu furnish will be used_to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the <br /> pernit or license. <br /> 3. The information may be shared with other local, state or federal a�encies to the <br /> exter�� necessary to process �ri� permit or license. <br /> 4. If vour requested permit or Iicense requires Council action to approve, some <br /> information may become punlic. <br /> �. You have cer�ain ri�rts under M.S. 13.04 (see fo?lo�x�ing paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIl�''T <br /> I�l Il,C.(l�v� �1 �U� �M�.l,l.. <br /> First Middle Last <br /> /��S �J�-�/��� �72.1�� <br /> Address <br /> ��� ��t�1� C`�,� ��--7 �ia- �r 3�-l'�qa <br /> Cirv State Zip Phone <br /> I u ders nd my ' s as stated abo��e. <br /> S i Qnature <br /> V TELEPHO?YE-473-7357� E.�►-473-0510 <br /> 10 <br />