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. t <br /> -� <br /> "<1 ��L� <br /> � �����:��� CITY of ORONO <br /> �*.+-�C..��:!-s��� <br /> �.��� '��s r,t �'�'n�: <br /> ��, ;;,�'�.<:t <br /> r..` "'.�`,�� <br /> S� � . r�1�S� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> .i�iu,.�:'�����3ci+� <br /> `��''�o � "' On the North Shore of Lake Minneton.ka <br /> 'f, . f� � A .�' <br /> DAT.pi__PRIVACY 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 license <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 /> l. 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 local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <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 full name, and date of birth are required to process <br /> this application or permit. <br /> _ ----- -__ _- - -- -- -- __ -- --...__ .._ <br /> _ __._. . ---- <br /> First Middle Last <br /> Address <br /> - - ----- <br /> - _ . . -- __ ____-- - --- - .. ._..- - -- - --. ._ ..- -- _ __ . - -- - <br /> City State Zip <br /> _ .._ _ ._ .- -- <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDiNG&ZONING—473-7357 � ADMINISTRATIOh&FINANCE—473-7358 • PUBLIC Y�'ORKS—473-7359 <br /> ASSESSII�G <br />