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, � :�r NOV-�1-2006 TUE 01. 15 PM AMERICAN EXPR�SS FaK N0. 6126710586 P, 05 <br /> pATA PRIVACY ACIVI$ORIf <br /> In �ccordance with M.S. 13.Oa, Subd. 2, "Rights of s►,bje�ts af data",.we waufd lik�to inform yo� <br /> that your request for a permit or Ilcense irom the City of qrono or any af its departments m�y <br /> require you to furnish certain priv�ta or confldentlai intormation. � <br /> You ere notlficd that: � � <br /> 1, The information yau furnlsh will be used to determine your qualification for she permlfi or <br /> Iicense reql�ested. � <br /> 2, You may�efuse to supp�y data, b�ut refusal may require that the City deny the pennit or � <br /> license. <br /> 3. Th�Information may be shared with other lacail,state or fedan�l �gencies to the extent <br /> neoB�sary ta process the permit or license, , <br /> 4. If your requested permii or license require9 Coynall �ction to apprave, s�me informatfon <br /> may become public, <br /> 5. You have certain ri hts under M,S. 13,04 (sae follvwln <br /> 9 g page)to reviaw prlvate data on <br /> yourself. ' <br /> ; <br /> 6. our full name is required to process thfs�pplieatlon a p�rmft. <br /> 1 I V r � ' C..JW� . <br /> �rst �1� M'ddle , a$t <br /> _� <br /> Address 11 W�f��U ��;1J ��.�J�. <br /> c� �5 �7� -��� <br /> State Zip Phonc� <br /> I un ret n y r��hts as ate o . , <br /> )gn ure . <br /> ' Qya }J Y �ji i��.:.SjM'� <br /> � ��� �`� ,(.�'7�^.�Y'�i:V,.S� Cj'1���1•_�'.i,i .�.'.::•JL'rP'� � <br /> l <br /> ,lt� ,�r .� :-7 �i , r � <br /> : � � n <br /> ��u-"���� � �a � �� <br /> �� t`•':'�;.�.,� ,J � �...._. � .!' L 1 <br /> r • <br /> ' <br /> { <br />