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� <br /> . � � �' �,' <br /> ,. <br /> ;;O o ��,�, <br /> �� -- ����� CITY of ORONO <br /> '� ;";�`,.��-r�� ; , ri„�;� oes� <br /> I�,� ,t l,'�^,-_� �+,; � <br /> � Posi Offxe Box 66 <br /> \\�' �t. �'' �1-�`� 'ti i; crystal Bay,yfinnesota 5532'�0066 <br /> ,� ir.�/�: � G <br /> ,\L ; .:,�:!';�=�'� 4� � <br /> �`�k��$og'�' <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.0=�P Subd. �• ���aetfroms the Ciryiof Orono or�ana lo e to <br /> inform you t ha t y o u r r e q u e s t f o r a p..r m i t o r l i c <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 }�our quaiification for the <br /> permit or license requested. <br /> �. You may refuse to supply data, but refusal may require that the Ciry deny the <br /> permit or Iicense. <br /> 3, The information may be shared with other local, state or federal a�encies to the <br /> extent necessary to process the permit or license. <br /> 4. If ��our requested permit or license requires Council action to approve, some <br /> information may become public. <br /> �, You have cenain rights under M.S. 13.04 (see followina paQe) to revie�v private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIl��"T <br /> i n���L,L l/�N� ��C'A N'� �/VA f'� <br /> �" , Last <br /> First Middle <br /> �' s. ,� � c'- _ <br /> Address <br /> '�� /(f �S J S �� /1-/L�i - l�� �d _ <br /> �i/a Uhl� � � <br /> Cirv <br /> State Zip Phone <br /> I understand my riahts as stated above. <br /> ��/ r� <br /> Sianature `� <br /> ` T'ELEPHOtiE-473-7357 � F.�.Y-i73-0510 <br /> IQ <br />