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� <br /> ��� r <br /> � <br /> '-�` <br /> � . _ "�''�����;G.�n <br /> _ -����� �ITY of �R�II\TO <br /> � <br /> , T, <br /> ��_-^� �� Post Office Box 66•Crystal.Bay,Minnesota 55323•Municipal Qffices <br /> �,a�w <br /> � � On the North Shore of Lake Minnetonka <br /> Cv ' i..6. A�° <br /> .. . ._ <br /> DATA__PRIy_ACY ADVISORY <br /> In accordance with M.S. 15.165 , "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or Iicense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> ::icense. <br /> 4. If your requested permit or license requires Council action <br /> tc approve, some ir_formation may become public. <br /> 5. You have certain rights under ri.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> --- <br /> � �S�,-Z� <br /> -- <br /> �����p''--- __ _------- <br /> - - - - - -- - <br /> - - -- _. _ . M - <br /> First .iddle Last <br /> � �`/S'� ��'1�z�'���,, �Gt��(� - - _ <br /> Adctress � <br /> � � <br /> ���`��� �"r r�� J -- - -- -- - <br /> City State Zip <br /> ���� ����� <br /> 1 - ___ ___--__..--.-- <br /> Phone <br /> I understand my rights as stated above. <br /> .-, <br /> ; ,. � �/ 1 <br /> • �L <br /> Signature <br /> BUtLII[NG&ZO'�[NG—473•i 3.i7 • ADMINISTRATIOti K FINANCE—473-7358 • PUBLIC WORKS —473•7359 <br /> ASSESSI\G <br />