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. , . <br /> . ����v <br /> � � �`�� <br /> �0 � <br /> �' =� CITY of ORONO <br /> ��� ,� , � � <br /> � ,,�t� t��;��_�� � �' M�,�o�� <br /> 1� Y <br /> � �i, =}'. ����_i �'� � POSt OffiC0 BOX 6G <br /> ,� "" '�'� � 1�� ���' stal Ba '�firu�esota 55323-OOG6 <br /> � ��•, r � C�Y Y+• <br /> w I� . �.� : <br /> ��ESH��,= ' <br /> _� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Riahts of subjects oi data , we would like to <br /> ,� <br /> inform you that your request for a permit or license from the Ciry of Orono or any of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish wi11_ be used to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to suppl�� data, but refusal may require that the City deny the <br /> permit ar license. <br /> 3. The information may be shared with other local, state or federal agencies to th� <br /> exter�t necessary to p:ocess th� permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. I�ou have certain ri�hts under M.S. 13.04 (see fo?lo�*�ing �aQP) to review privzte <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRII�� <br /> /�✓<�C�'� � <br /> )�v�y � ��[��" <br /> First —�—�ie Last <br /> � ��� ��l���c� �lin ,.�/'�� <br /> Address <br /> �'�/� � ��l�� i���� � S��� � �u- Z-�1� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> �1 <br /> iQnature <br /> ` T'ELEPHONE-473-7357• FAX-473-0510 <br /> 10 <br />