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„ � `•. <br /> __� ' bi <br /> � <br /> O -� � ����� <br /> C I'��' o� <br /> � ;,:�, ,,., .tunicip�o� <br /> � �y Post�'e Box 66 <br /> �� '�• ' -- �. �j'�' Crrstal Bay,�liiviesota=5323-006G <br /> L�kEs H�4� <br /> DAT:� PRIV�CY ADVLSORY <br /> In accordanc� «'It�l �T.S. 1�.01. Sllbd. �. ��Rivnts oi subjec�s o� daca”, «�e would like to <br /> inform ��ou that vour :equest for a p�rmit or license irom the Cir�i or Orono or any of its <br /> depanments may require ��ou to i�srnisn c�nain pri�'a�e or contidential inrormation. <br /> You are notified that: <br /> l. The info�nation �'ou nzrnish «'ill be used to determine ��our quali�tcation for the <br /> permit or license requested. <br /> �. You may refuse to suopl}� daca, but refusal may require tnat the Ciry der.y the <br /> �;ernit or 'icense. <br /> 3, The information may be snared «�ith other local, state or federal aQencies to t}:e <br /> extent necessary co p.'o��ss «l� �z�r•��j or license. <br /> 1, If ��our requested pe:mit or license requires Council action to approve. sorrie <br /> inrormation mav becom� puoiic. <br /> �. You ha��� ce�ain ri�rts unde: ��I.S. 13.0? fs�� follo�vinR pa��i to revie�v pri��te <br /> data on �-ourself. <br /> 6, Your ru11 name is :�quired to process this applicacion or permit• <br /> PLE:��E PRLV"T <br /> 5;�,.- <br /> ��;-,��:�.- �'a,� (< <br /> -��t�t��-;r ��c=, ,,-,rt_� ►1 <br /> First <br /> :`�1idd:e Last <br /> � (� �,�. � <br /> ��ddress <br /> �' i i..t..l �_��; �t y �:�� �-1 `i�� , � <br /> ��1;�,u ��.�- Zip Phone <br /> Citv Jta�e <br /> I understand my riQhts as sraced above. <br /> � 4 <br /> . '." ., ., ]�., �1� ��� a <br /> ( r�.1 <br /> t........... \.. <br /> Si�nacure <br /> � TEL.EPHO?YE-�373-'T357• F.�,X-i13-0510 <br />