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, � <br /> � o � <br /> O � <br /> C ITY of ORONO <br /> ,� � ; �•:. � .t���►ofs�� <br /> �� :r ;' c� Post Office Box 66 <br /> �� . ,` � . .�. �j�' Cr�stal Bay.vlinnesota 553Z�--0066 <br /> . ; <br /> �9kESH�4� <br /> DATA PRIVACY ADVISORY <br /> In accordance �vith �1.S. 13.0�, Subd. 2, "Riahts of subjects oi data", we wouId li�e to <br /> inform 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 are notified that: <br /> l. The information ��ou furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> ?. You may refuse to supply data, but refusal may require that the Ciry deny the <br /> permit or license. <br /> �. The information may be shared with other local, state or federal aaencies to the <br /> extent necessary to process the permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> intormation may become public. <br /> �. You ha��e certain riryhts under M.S. 13.04 (see followina paQe) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL\'T <br /> .�SCr� 1 � 'G�Ili�ctil T{�� i S <br /> First Midd,e Last <br /> �I l.i � 1—�5 In �o�: � ��.� <br /> address <br /> �`� r o r� 1'�'� ti ��5�C= `� - <br /> Citv State Zip Phone <br /> I understa� m � ri�hts as stated above. <br /> , � <br /> / �1------ <br /> j . L <br /> / j,dnature <br /> j� ; � TELEPHO'.V�-973-7357 • FAX-d73-0510 <br /> l� <br />