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. ; � ' Y <br /> � <br /> � - -; � ����� <br /> ��TY of <br /> ,� : ; �;'�. �, .t���o� <br /> ' � , �, r�o�soX� <br /> `'�'�� �,',ti .:--.- �ti, c�-�say.�t�oc�=�zs-oo� <br /> � .,' ��� <br /> �kESH�� <br /> �,�__ - <br /> DAT:� PRIV aCI' ADVISORY <br /> In accordance with �i.S. 13.0=�, Subd. ?. "Rivhts of subjec�s or data", �;�e would li�e to <br /> inform you that your request ior a p�rr.li� or license irom the Ciry or O:ono or any of its <br /> depanments may require vou to iurnisn cenain priva�e or confidential in�ormation. <br /> You are notified that: <br /> l. The inforrriation ��ou f�sr.iisn will be used to determine }�our qualification for the <br /> permit or licensz requesied. <br /> ?, You may refuse to suppl}' data, but refusal may require tnat the City der.y the <br /> pernit or license. <br /> 3. The information may be shared �i�ith other local, state or iederal aQencies to t?:e <br /> exter�t necessary� to p:ocess �:�z Permit or license. <br /> �. If ��our requested permit or license requires Council action to approve, some <br /> intormation may becom� public. <br /> �, You hav� ce��ain ri�rts unde: M.S. 13.0? (se� follo�s�in, paa�) to revie�v privzte <br /> data on yourself. <br /> 6. Your full name is requir�d co process this application or germic. <br /> PLE�SE PRLti''i' <br /> j"� . � -- <br /> First <br /> ` � '��fidd:e Last <br /> F. ��� � <br /> :�ddress <br /> , � �S�� ��� � ��� <br /> Cirv <br /> � � � State Zip Phone <br /> . - <br /> I under tand my ri�hts as staced above. <br /> � <br /> % - <br /> / _ <br /> S i_nature <br /> y TEL.EPHO'.YE-;73-7357 • F.AX-�73-0510 <br />