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� <br /> ����' �� (���i�T� <br /> 9/ Post Office Box 66•Crystal Bay,:4linnesota a-i323•Mnaicipal Offic�s <br /> � <br /> �- � . � �, On the North Shore of Lake Minnetonka <br /> DATA_PRI4ACY ADVISORY <br /> In accordance with M.S. 15.I65 , "Rights of subjects of data", we <br /> wouid Iike to inform you that your request for a permit or �icense <br /> f rom 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 deter:nine your <br /> quaZification 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 /> Iicense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself . <br /> 6. Your ful.l name, and date of birth are required to process <br /> this application or permit. <br /> . <br /> � <br /> � . � <br /> . <br /> .>_ '� _. ___ -- .._.----�-�.----�--- ----- - ----.�_._ �a� _�1�_�------- - <br /> irst Middle � <br /> � � - -��- 13 �.� --- - _l � - <br /> _ ___ <br /> Address � <br /> , �-- _ <br /> ` ---- <br /> ` ` -. -- <br /> _---�- - - <br /> � � � %l�____. . __.----- - _-- ---- <br /> .2 .�- -�1�._� ----- --- -------� _. . <br /> City State Zip <br /> �� �� '_ ��1 � ----- -- <br /> Phone <br /> I understand my rights as stated abone. <br /> � <br /> � i , �� j ^� <br /> y � <br /> ^ , <br /> . , <br /> ----. ._-�.- �----- <br /> ,�(.� " .__._.----- �-- <br /> � � _. .._,�. <br /> ignature , � <br /> r <br /> BUILDING dt ZONING—473-7357 • ADMINISTRATION�FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />