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, /j= O�\.� <br /> � � � <br /> ` O O <br /> .;' -, i��f Y�._.__ C ITY of OROl�TO <br /> �, a ��� ,, �.. � ����o� <br /> \�''� ��` ��� .y� _,��� F+ �� P�o�soX� <br /> � <br /> \;�� � �'i�j.� y f� ('j�' Crystal Bay,Dtinnesota 55323-OOG6 <br /> '� �,�, � '� <br /> ��9kE�: <br /> DATA PRIVACY ADVI.SORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rivhts of subjects or data , we would lil:e 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 /> 1. The information you furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City der.y tre <br /> rermit or license. <br /> 3. The information may be shared with other local, state or federal agencies to th� <br /> extent necessary to process tri� permit or license. <br /> 4. If ynur requested permit or Iicense requires Council action to approve, some <br /> ini�ormation may become puolic. <br /> 5. I�ou have ce;�ain ri;hts under M.S. 13.04 (see follo�x�in� paaP) to review privzte <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRLNT , . <br /> �" �/� � P <br /> First Midd:e ast <br /> -`� ����r�'�� '`'_ <br /> Address <br /> 1 _' �- —'�-- ,--� � -� � <br /> � j � � ���� <br /> i> - <br /> City State Zip Phone <br /> I understand my rights as stazed above. <br /> � ;� ��� <br /> �. <br /> Signature <br /> TEL.EPHONE-473-7357� F.AX-473-0510 <br /> 1� <br />