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� . . <br /> ' <br /> ,-__� _ <br /> � � � <br /> O - -� � ��� <br /> �I��' ��f �� <br /> � : '� � :;�:- _ �-, ,i���,o� <br /> ' � � F, P�ot�saX� <br /> �'',� ,:,�ti: :� �'� cn�stal Bay,�u�u,esota»�3�-0066 <br /> ,.' : <br /> ��kESK��� <br /> DAT� PRIVACY �DVI�ORY <br /> In accordance «-ith �i.S. 13.0�. Subd. ?. "Rivhts of subjec�s or data", we would like to <br /> intorm you that your request ior a permit or license irom the Ciry ot Orono or any of iCs <br /> departments may require ��ou co turnisn cercain priva�e or confidential intormation. <br /> You are notiiied that: <br /> 1. The info�rnation you turnish «�ill be used to determine ��our qualification for the <br /> permit or license requested. <br /> ?, You may refuse to suppl}� da�a, buc refusal may require that the Ciry der.y the <br /> �ernit or license. <br /> 3. The information may be shared ��ith other local, state or iederal aaencies to t�.e <br /> extcr.t necessary� to pro��ss �ij� Pz��it �r ticense. <br /> �. If vour requested permit or license requires Council accion to approve. sorrie <br /> intormation may becom� pubiic. <br /> ; You ha��e ce;.ain ri�hts unde: �I.S. 13.0� (see fo�lo���in, paQ�) to review privzte <br /> � data on ��ourself. <br /> 6. Your iull name is required to process this applicacion or permit. <br /> PLE�,�E PRL\''T � <br /> ��� Irf <br /> = � ������- � <br /> First �liddl� Last <br /> -� , � �, <br /> �,�, ,�� ��c�u i.� �� �� <br /> _�ddress ��� �/ � <br /> � � ��I- ��� �` / / ��'1 � ,� <br /> '\�(;i � �_C��'(,� <br /> Ciry <br /> � Stace Zip Phone <br /> � I understand �n�h1�'as.�taCza ����'z• � <br /> � � <br /> � <br /> ,� ,� _ <br /> Signarure " <br /> " TELEPHO.�YE-�7357• F.4X--t73-0510 <br />