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� <br /> o �,. <br /> 0 0 <br /> CITY of 4RON0 <br /> ,� ' A . � `z,�,;���►or�� <br /> ;r ,� Post OtTice Box 66 <br /> �� `1 •• . . : � Crestal Bay,�finnesota�5323-0066 <br /> ��kESI3�4� <br /> DATA PRIVACY ADVISORY <br /> In accordance «�ith M.S. 13.04, Subd. 2, "RiQhts of subjects of data' , we would like to <br /> , <br /> inform }�ou that your request ror a p�rmit or license from the Ciry of Orono or any of its <br /> departments may require ��ou to furnish cercain private or conridential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine ��our qualification for the <br /> permit or license requested. <br /> ?. You may refuse to suppl�� data, but refusal may require that the Ciry deny the <br /> pei-rnit ar license. <br /> 3. The information may be shared �vith other local, state or federal agencies to the <br /> extent necessary to process the permit o. :icense. <br /> 4. If ��our requested permit or lieense requires Council action to approve, some <br /> inrormation may becom� punlic. <br /> �. You ha��� certain ri�hts under M.S. 13.01 (see follo�vin� paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�T <br /> � �t � <br /> /�����r`� _.�914h" oll�!?Lc' 7'` <br /> irst ��Sidd.e Last <br /> 7 <br /> ����� �^ ���1 s�� ��� �`��- <br /> �ddress <br /> , � , <br /> f�e i�� `�+�a!/,`� ���� ����'� ��y= �'S�� <br /> Citv State Zip Phone <br /> I unders d my riQhts as stated above. <br /> � <br /> ,Z. ����f�, , � <br /> S anature <br /> � TELEPHO!YE-473-73�7� F.�.Y-�73-0510 <br /> 10 <br />