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// � _ � � <br /> � � <br /> O O � <br /> � ��T�'" of �R�N <br /> � ':�.- _ ,,., .i���ot� <br /> r�'� �_ P,N Post Offic�e Box 66 <br /> � , ,` ;ti- - `.�. �j�' Cn�stal Bay.`tinnesota»3230066 <br /> . j <br /> �9kESHa�� <br /> �__.: <br /> DAT:� PRIVACY ADVLSORY <br /> In accordance «�ith `i.S. 13.04, Subd. ?, "Rivhts of subjeccs or daca", �ve �vould like to <br /> inform ��ou that your request ror a p�rmit or license irom the Ciry of O:ono or any of its <br /> deoartments may require �rou to rurnish c�nain pri��a�e or contidential in=ormation. <br /> You are notified chat: <br /> l. The info�na�ion ��ou rurnish will be used to determine ��our qualification for the <br /> permit or licensz requested. <br /> ?. You may refuse to suppl�� da�a, but refusal may require that the Ciry der.y the <br /> pernit or �icense. <br /> ;. The i.�forma�ion may be snared �;�ith other local, state or iederal aQencies to the <br /> e�ten� n�cessar}' to p.'o�ess «�� P���;t or licer.se. <br /> �. If vour requested permit or Iicense requires Council accion to approve. sorrie <br /> intormation mav become puolic. <br /> �. You ha��� ce-:ain ri�rts unaer �I.S. 13.0^ (se� fo�lo���in, paQP) to revie�v privare <br /> data on ��ourself. <br /> 6, Your full name is required to process this application or p�rmit. <br /> PLEA�E PRL�'T <br /> ��►���T I�f��'T�N <br /> First �1idd;e Last <br /> �N � �� � <br /> a ddress <br /> o�oNo MN ��3�l I �'l�•��l <br /> C itv <br /> State Zip Phon� <br /> I understand my riQhts as srated above. <br /> Sianature <br /> ✓ TEL.EPHO!V�-�'7�%357• F.AX-�73-0510 <br />