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' � � �� <br /> /� � O�\ <br /> � \ <br /> �/O O\,� <br /> �, <br /> '� . , `' C ITY of ORONO <br /> � �, . �, <br /> Illi r� ,�'���r'��.� '.. �/j Municipal O�ces <br /> ��i, 1� �`h'-�,���r ` � Post Office Box 66 <br /> ,r��: <br /> � � �^,:��� G~':/ cry�ssy,��ss�z3-oo� <br /> I , <br /> t`�kESYi�g'� <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 you that your request for a permit or license from the Ciry 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 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 /> perrnit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to p:o;.ess the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may became punlic. <br /> 5. You have certain ri�hts under M.S. 13.04 (see followina paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIN'T <br /> J�J'fi.S � �i��� <br /> /�� ► �[l/✓ <br /> First Middle Last <br /> �f �f �� ,�-���.rr� � �r� <br /> Address <br /> ��1��'�,lJ1hf,� ��� ���� � �)7�/�� <br /> Ciry State Zip Phone <br /> I understand my rights as stated above. <br /> v,�'�"fi����.'' <br /> Sign�ture <br /> ` �HorrE-a�-r3s�.Fax-a�-osio <br /> 10 <br />