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� � <br /> ,r � �.�y <br /> /o o����������,, <br /> � ��=�- ,� ���� C ITY o� ORONO <br /> � , a� �� <br /> '1� A r� r'�' �' �" ' ,����ot� <br /> , '� ti - P�oe�soX� <br /> ��j i'`�'�i�'�' �, ���„ �j'�',�� Crystal Bay,:�finnesota 55323-0066 <br /> \ ` 4 � ` ` <br /> ESS �/, <br /> � <br /> �V`qk' p.Q„ � <br /> ,�_�� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.0=�, Subd. 2, "Rivhts of subjects or 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 conf'idential 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 Ciry deny the <br /> �,ermit or license. <br /> 3. The information may be shared with other local, state or federal a�encies to thE <br /> exter�t necessary to process tri� permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> ini�ormation may became puolic. <br /> 5. I�ou have ce;�ain ri?hts under M.S. 13.04 (see fo?lo���in� paQe) to review priva�e <br /> data on yourself. <br /> 6, Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> �.��1� [�!�-T���' ,� . <br /> First Middle Last <br /> I���t�� \/I�-1 �nK.. '�`-�- .L�� �1L'7 — <br /> Address <br /> � .�_ - i�111 ���-� `'f`IL 1��� <br /> Ciry State Zip Phone <br /> I unders nd my rights as stated above. <br /> �., <br /> _ .�-� <br /> S ignatur <br /> TELEPHONE-473-7357�FAX-473-0510 <br /> l� <br />