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�.� .. : <br /> CIT�of O]E�ONO <br /> Post Office Box 66•Cryatal Bay,Minnesota 55323•Municipal Offices <br /> •. <br /> � _ � � 4� On the North Shore of Lake Minrcetorcka <br /> DATA PRIVACY ADVI_SQR7C -- - <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would 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 confidentia3 information. <br /> You are notified that: <br /> 1. 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 Ioca3 , state or <br /> federal 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 full name, and date of birth are required to process <br /> this application or permit. <br /> • _�,� . .-�------------ ------� <br /> F�t � Middle � Last <br /> �c�SS �..� 1Rc� l9 - ----_ . ... ._ ._ <br /> �Address <br /> V`�a+a,,ui �. JY�n? SS36� -- - -- --- - <br /> City State Z1p <br /> �y�a.- 5"1 tS _ . . . _ <br /> -- �---.. .._.. ._.-_-- --- <br /> Phone <br /> I understand my rights as stated above. <br /> � ---.. .------�---- <br /> ..__.._..__.._. .--�-----._ <br /> Signature <br /> BU[LI31NG&ZONING—473-7357 • ADMINISTRATIOIV&FINANCE—473-7358 • PUBLIC WORKS—473•7359 <br /> ASSESSII G <br />