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, � <br /> � ;: o .�,., <br /> � <br /> '� � � '�7�' o� O�iON� <br /> ., _ C�. <br /> '� ;-:a,;:`Y=�' _ ii��t o� <br /> �.z, 1 �;;��.r ' '�'' Posi O�ce Box 65 <br /> '' � <br /> � - <br /> \'�,r '�r' 3' ,ll_i �j �.,. '� crysrai say,�,un�a���oo� <br /> \� �„•-� - ;�. . � C� <br /> �� ,,;_� <br /> �l ; .":i�;�_ �� � : <br /> �� .q��xo4`„ <br /> DAT:� PRNACY AD�ORY <br /> In accordan�e with �1•S. 13.0�, Suod. �licensaetfroms the CINIOT Oro oe oroana lor�ics <br /> iniorm �rou that your request for a p�:mit or <br /> d��an,.nznts ;nay rea,uire vou to rurnish certain private or coniidential uiiormation. <br /> You ar� notiiied :hat: <br /> 1 Z-;-�� intormation you furnish wiil be used to determine �rour qualirication for th� <br /> permit or licensz requesced. <br /> �. You may re:use to supoly data, but refusal may require that the Ciry deny th� <br /> pe::nit or license. <br /> 3, The inforr,iation may be shared with ��I Iicense.s�te or federal aaencies to the <br /> extent necessary to process the perrnit o <br /> :�. If ��our requested per.*nit or license requires Cour.cil action to approve, sorn� <br /> information may become public. <br /> �, You have certain riahts under M.S. 13.04 (see followin� paae) to revie�v private <br /> data on yourself. <br /> 6, Your full name is required to process this application or permit. <br /> PLE�SE PRL�"I' <br /> �, � - � ,� �- � �� �� �� ' <br /> �� <br /> First <br /> Middle Last <br /> � . <br /> � �� l��iL_l.� �l <br /> r�ddress � ,� <br /> '�l �-' �:�� �`-� - r `��� <br /> `� �l,/ � ►�'� �- ' � <br /> Cirv <br /> State Zip Phone <br /> I under�t.and my riahts as stated above. <br /> � <br /> � <br /> ; � <br /> � ��,��"ni'v <br /> � <br /> Si�narurz � <br /> TEI.EPHOr�-�73-73�• F�..Y--t73-0510 <br /> 10 <br />