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� <br /> �—�� <br /> O�_, <br /> � ' r <br /> O 0 <br /> -- ciTYo� oRONo <br /> ,,, � � �. _ � �„o;�;�o� <br /> � �, �-` �' Posc o�Ce sox 66 <br /> � ,,'�� _ .,� �j'y Crystal Bay,Minnesota 55323-0066 <br /> � j r <br /> 't`9kESIIOg'� <br /> , : , <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data , we would like to <br /> inform vou that your request for a permit or license from the Ciry of Orono or any of iu <br /> departments may require you to furnish certain private or confidential 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 /> �ermit or ticense. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary tu p:ocess the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become puolic. <br /> 5. You have certain ri�hts under M.S. 13.04 (see following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIl\"T <br /> � �,... <br /> `'j;��,z, �. 'c� �. v v�n m �N�� <br /> First Middle Last <br /> , � �� ..��� �' <br /> Address <br /> ' �_� �`i I � � 1 nU� 0 <br /> �,,j �r���,,�-�-�p ..�''� w <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> 1'ELEPHONE-473-7357�FaX-473-0510 <br /> 1� <br />