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, , , <br /> � O� <br /> O O <br /> � CITY of ORONO <br /> �; � _ <br /> � , <br /> ��, ,� ���� �r� _ �� <br /> \,\� �p z,�,_ �4� �� �ti/ Municipal Offices <br /> � <br /> � ,�t��r�ti� G Street Address: Mailing Address: <br /> I E88 g'� <br /> �`��C O 2750 Kelley Parkway P.O. Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323-0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br /> to inform you that your reque:>t 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 are notified that: <br /> l. The information you furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> r.�;�. <br /> '����1�.;;.,.,. <br /> 2. You may refuse to supply data, but refiisal may require that the City deny the . .' � <br /> perniit or license. '-'� <br /> 3. The informatio�z may be shared with other local, state or federal agencies to the , <br /> exterit necessaiy to process the permit or license. � <br /> 4. If your requested permit or license requires Council action to approve, some ~-�`� <br /> : i <br /> information m��y �ecome public. ' <br /> v;� <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private -E._�`� <br /> data on yourself. � >�`<� <br /> 6. Your full name is required to process this application or permit. <br /> , .. <br /> L.��ti't �=_ L- . �-i�-e; <br /> First Middle Last <br /> �-4l� �Q��f l� �� L.�cr�� ��� <br /> Address <br /> �' � � �i �l M NI ���/ �f � � I GQ� <br /> City State Zip Phone <br /> I understand my riglits as stated above. <br /> , � <br /> J�� �'6'��� <br /> ignature <br /> 7Celephone (612) 473-7357 • FAX 473-0510 <br /> 8 <br />