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/ O \� .\ <br /> � � � ���� <br /> �/ O :�. O '�;�, <br /> �( �;a�� ���= , �� CITY of ORONO <br /> 1 � ,t� ,�r,.., �,, ; ���,oe� <br /> ;� - �J _�-- c�i� Pasc o�ce sox 66 <br /> \�� ! �;':� ,..i Q��� G'�/� c��y,��ss�z3-oo� <br /> ��kE8IH�4� // <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 /> yermit ar Iicense. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to p:ocess thz permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. You have cenain rights under M.S. 13.04 (see followin� page) to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRIl�'T <br /> ��RT M XU1'�U- �G� <br /> First Middle st <br /> ZZ-� O vJ�S�z�� �L� _ <br /> Address <br /> ,ntiev..�.� ,� �s��4� �1��7�-�d7 Z <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> 1'EI.EPHO!YE-473-7357•FAX-473-0510 <br /> 10 <br />