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. � - \ <br /> . � <br /> -� . .� <br /> �... .�� � � f OIEi�NO <br /> �IT o <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> �: <br /> � _ � A � On the North Shore of Lake Minnetonka <br /> DA�A_ PR�VACY 1_�DVI_SORY - <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> wou3d like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br />� qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local, state or <br /> f ederal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your fulZ name, and date of birth are required to process <br /> this application or permit. <br /> . _. ._.----- -----�-- -� ---�- ---.. .---�---�- --- - --- <br /> . - �----� <br /> First Middle Last <br /> Address <br /> -----. ....-----. .._..------ -.._ --- _ ......-.--State� --._.. ..__ _-___...ZiP <br /> ...__. <br /> City , <br /> _.. ........ ..... .-�- -- <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BU[LDING&ZONING—473•7357 • ADMINISTRATION&FfNANCE—473-7358 • PUBLlC WORKS—473-7359 <br /> ASSESSI\G <br />