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�,�., <br /> "�R ��� : <br /> a ;sfs .. <br /> - � �h� CITY of URON(� <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data", we would 3ike to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to 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 license 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 local , s`ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> tc appr�ve, SCm� inior��satior. m�y �e�o^?e pub?ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ��� ,�1�,��!� �� r.:� - � <br /> First Middle Last <br /> � � �� �� C,���., ( ��u��� �l _ <br /> Address <br /> ��,���� � �� ,v � � / <br /> Cit State Zip� <br /> ��� �7l` �'� � �?� (� � � t c r C� � �' S �' � � <br /> Phone <br /> I understand my rights as stated above. <br /> . � <br /> Signature <br /> BU[LDING&ZO[YING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />