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� <br /> � � <br /> � - -: � ON(� <br /> ��'��' of O� <br /> ,� : �> i;�;�,:- _ �, �t��►ot� <br /> .�. i_ £y Posc oi�ce sox s6 <br /> `'�,� ,• ,ti- - ��. �ti Crystal Bay.�linnesota=532�0066 <br /> , . <br /> L�kESH�4� <br /> ��_��.� <br /> DAT� PRIVACY AD'VISORY <br /> In accordance «ith `i.S. 13.0=�. Subd. ?, "Ri�hts of suojeccs o� data". we �,vould like to <br /> inform ��ou �hat your request ror a p�rrnit or Iicense from the Ciry oi Orono or any oi i�s <br /> departments may require �-ou to iurnisn cenain pri��ate or coniidential inFormation. <br /> You ar� notitied that: <br /> l. The info�nation ��ou furnish will be used to determine }�our qualification for the <br /> permit or license requested. <br /> ?. You may refuse to suppl�� da�a, but refusal may require that the Ciry der.y the <br /> pernit or �icense. <br /> 3. The information may be snared «�ith other local, state or federal aaencies to the <br /> exten� n:.cessary� to pr��ess �.1� Pe:mit or license. <br /> �. If ��our requested permit or license requires Council action to approve. some <br /> inrormation mav bec�m� �ubiic. <br /> �, You ha��e ce-ain ri�hts under �I.S. 13.0^ (see fo�lo���inR paQ=) to revie�v private <br /> data on yourself. <br /> (, Your full name is required to process this application or permit. <br /> PLE�SE PRL'�'`I' . <br /> � —.I�1�til� e'�c:t��'J�r. ��{�' <br /> ���� L,3Si <br /> First �1idd:e <br /> .. � �,� �,- <br /> � -_7 " <br /> .�, dress <br /> � ��� � �� ���� <br /> ��Q�v �1'��r�� �'I .��� g <br /> Ciry <br /> Stace Zio Phone <br /> I understand my riahts as staced above. <br /> � � <br /> S ianarure <br /> V T'ELEPHO?V�-4'7�7357 • FAX-�373-0510 <br />