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- � ,,�T <br /> � � d' <br /> O -� � ��� <br /> C�T� Of �R <br /> � , � ;;�.- _ �., ,i���o� <br /> ,� ; ti P�oe�s�X� <br /> `r . � <br /> 'r.� �l, �,_ G�' c��saw tiu�ta_�-�_3-00� <br /> . ; ' <br /> ��kESH�4� <br /> _�_,. <br /> DAT� PRIVACY ADVLSORY <br /> In accordance with �i.S. 13.0-�. Subd. �. ''Rivhts oi suojects o� daca". we would iike to <br /> inform ��ou that your request ror a p�rmit or license rrom the Ciry or Orono or any of its <br /> departments may require ��ou co rurnisn cenain pri��ate or confidential information. <br /> You are notified that: <br /> 1, i he informacion �•ou rurnish «�ill be used to determine ��our qualiitcation for the <br /> permit or licensz requested. <br /> 2. You may refuse to suppl}� da�a, but refusal may require *�hac the City der.y tr�e <br /> pernit or license. <br /> 3. The L�formation may be snared with other local, state or federal aQencies to t!:e <br /> exter�t necessary co pr�::ess �.�� pe:m�t or (icer.se. <br /> 1, If vour ;equested pe:mic or license requires Council action to approve. some <br /> inrormacion mav oeccm� oublic. <br /> �, You ha��� ce,�ain ri�hts unde: �v1.S. 13.0^ (se� IO�10�'•�1r1�T paQ=) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this applicacion or permit. <br /> PLEASE PRL�'T ' <br /> `� / ,/ <br /> � `rliddle Last <br /> First , <br /> - , - ��, �� ,(- :? ,• <br /> �addr�� )� ", . . � <br /> � . <br /> ' �� , f � � � i � � , � <br /> C ity <br /> State Zip Phone <br /> I understand my riahts as sta�ed above. <br /> _�, - <br /> �� ' -�� l�,li; <br /> , , � . <br /> Sianature <br /> v , TEI.EPHO?YE-�i'T�7357• EAX-373-0510 <br />