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� <br /> o� <br /> o��_:. o <br /> � -==Y�=��:� CIT�' of OI�OI11'O <br /> ,.,:3i.t� � <br /> ' � a�'i • .. • <br /> .�� � <br /> � ,t,. �� ; � �, hlunicipal Offices <br /> r=•.'{��.i:.�;��:'!. '1� <br /> ��r !��,•,=1.;:.�`�t��G SVeet Address: Hailing Address: <br /> '�ES�Qg' 2750 Kelley Par{cway P.O. Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323•0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance �vith M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to <br /> inforn you 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 confidential information. <br /> You aze notified that: <br /> 1. The information you furnish will be used to determine your qualification for the ,� <br /> permit or license requested. <br /> �.;� <br /> 2. You may refuse to supply data, but refusal may require that the City deny the pernZit <br /> r�, <br /> or license. - �` � <br /> . �. <br /> 3. The information may be shared ��zth other local, state or federal aaencies to the v�`' <br /> extent necessary to process the pemut or license. , �"' <br /> �' <br /> ��.� <br /> `��, <br /> 4. If your requested permit or license requires Council action to approve, some � "`.� <br /> information may become public. �� <br /> ,k� <br /> �. You have certain rights under M.S. 13.04 (see following page) to review private da ��9 <br /> on yourself. <br /> 6. Your full name is required to process this application or pern�it. <br /> �� ��� <br /> First Middle Last <br /> 2-�� �4 r�--t�v` <br /> Address <br /> �IV�u 2�., (�11�j 5534 t ���Z'� rl <br /> City � State Zip Phone <br /> I stand my rights as stated above. <br /> Sib <br /> Telephone(612)249-4600 • Fax(612)2A9-4616 9 <br />