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� r 4 <br /> � V � <br /> � � <br /> O _•_ � �� <br /> (��'��' of OR� <br /> � ',;�. �, «���o� <br /> ,��, � ;;, :�, ti P�ot�soY r� <br /> .�, ,% ��; - :,, G`� c��sa�,�u�ta s�z3-oo� <br /> - <br /> ��kES�I�4� <br /> DAT� PRIVACY :�.DVLSORY <br /> In accordance «�ith `i.S. 13.0�, Subd. ?, "Rivhts of subjects or data", we would li�e to <br /> inform ��ou that your request ror a o�:rnit or license irom the Ciry of O:ono or any oi its <br /> departments may require ��ou to iurriisn c�nain pri��ate or coniidential information. <br /> You are notified thac: <br /> 1. The info��a�ion ��ou furnisn «�ili be used to determine ,�our qualification for the <br /> permit or license requesLed. <br /> ?. You may refuse to suppl�� da�a, but refusal may require that the Ciry der.y the <br /> pernit ar 'icense. <br /> 3. The information may be �hared �i�ith other local, state or federal aQencies to t?:e <br /> extent necessar}� to pro�ess «,� �e�m;t or license. <br /> 1, If ��our reques�ed permit or license requires Council action to approve. sorrie <br /> ini�ormation may becom� �uoiic. <br /> �. You have ce-:ain ri�rts under VI.S. 13.0� (se� fo?lo�j�in, paQ=) to review private <br /> data on ��ourself. <br /> 6. Your fu11 name is required to process this applica�ion or permit. <br /> PLE��E PRL\'T _ <br /> �c) i.`� �� �-1 VS� �. � /�l w � <br /> First '`�iidd:e Last <br /> �`, � �'L- <br /> c j � S� ,.J �c��, �b�-�-- `lt-- <br /> .�ddress <br /> v� �� ,�.. -��� � ��1 5:s����s �z y3�� _� <br /> Citv StatP Zip Phone <br /> I understand my riQhts as sraced above. <br /> -�� �� ��- � �— <br /> Si�na�ure <br /> " ���o�vE-sr3-r3��• Fax-s�osio <br />