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• rrom: U4/19/1UU6 Uy:39 #U1/ N.UU3 � <br /> HNh-1'9—CIIUhI,WtUI Uys t1C F'. UU�/UU�i <br /> pATA PRIVACY AI?VISORY <br /> !n �ccordance with M.S, 73,04,Subd,2, "Rights of subJeets of dafia",we would like to infcRn you ' <br /> thet your requast for a permit or)icensQ fhom the Clty a!Orono or any of ib departments may <br /> r�quira you to fumish �ertain privat�or Gonfidential informetian. . <br /> Yvu are nvtified th�t: . � <br /> 1.� The lrtformeti�n you furnish wil!be used to det�rmine your qualifi�at(cn farthe permlt or <br /> licanee requested. • . . <br /> 2. Yvu may refuse to supply date, but refvsal may requlr�that th�City deny the permlt or . <br /> license. <br /> � 3, The infot�metf�n may be sha/�d wltA otR1�r local, �tate 6r federal agencies te the extent <br /> ' • necessery to process ths permit or 1lcanse. <br /> 4. If your requested permit or license reqyires Council sdion ta epprova,sam�informatton <br /> may bocome pub►!c. • <br /> 5. Yeu hava cert�ln rlghts under M.S. 93.04(ses fallowing page)to revi�w privat�data on � <br /> yoursalf. • <br /> . 6, Yvurfull name is requfred ta pracess this applicatien,ar perrnit. • <br /> �6X_LLYlV1G L � �i°cC.�'0Y� � N1�hV12"�hkCA �C//1iCv �r�'�"h' hvr'f� <br /> F�rst MiddlQ I„ast '—' <br /> a L�/v ivor rC-f-i �.ta D����z- • . <br /> . , <br /> �� M�1/ S3'3�/ �75;� y73 l'3�/ �zt i� <br /> � <br /> ���Y Sh�te Zip • Phone • <br /> I un tsnd my rlghf�,as stated above. , <br /> �/r�/� � <br /> , ig atu ' <br /> , . . . <br /> 't�l� � �.x'�"�,, �„s�7 ��� �.f; ' <br /> r`r'a�r� eJ {�,j �!� �S 7 :,�,.a.��;i I ��: <br /> ���e"^e« C:n'� 't:-:. �'�� .'� �5'�1 i <br /> �, "~ ;. ,�.,:•-• I �`,•• i <br /> r..i/ � . �� I t�t r,� i�+� <br /> ��i', .t �i`t y'.'1 �i7 �,i� <br /> •�.:.u.�ry n..:;w:d:l ��-a, �� �r,� f <br /> .. L°�':d � .. <br />