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� <br /> �� � <br /> �� <br /> � � ����������. <br /> ,;�/O O��������, <br /> �! -� � C ITY of ORONO <br /> i''I t:. <br /> � �.7� ����j�r _. �+�� Municipal OfPces <br /> � � Post O�ce Box 66 <br /> } <br /> ��'� i��`,�0'�i������•,F���� ��,;� CrystalBay,Mim�esota5532.3-0066 <br /> \�\�kESII�4� <br /> \�� <br /> DATA PRIVACY ADVLSORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data , we would lil:e to <br /> inform vou that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confidenual uiformation. <br /> You are notified that: <br /> l. 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 deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal aQencies to the <br /> extent necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see followin� page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�'T <br /> ��c i� ��� L�z/ l L l ��-�a «���--�'l��� <br /> First Nliddle Last <br /> � � �-�J�l� l��-(2��`( l� t � �— <br /> Address <br /> L c� �ir �;3� �- ti� r y �S'� �� `�"73 s^S- z v <br /> Cirv State Zip Phone <br /> I understand my riahts as stated above. <br /> ��.-��� L�G!��-�—�'_ <br /> Sianature <br /> y T'ELEPHO'.V�--t73-73�7 • E��-473-0510 <br /> 10 <br />