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._� <br /> '� �� <br /> -��o o�� � <br /> � .,t��,. � CITY of �RONO <br /> �. ,� �� . . � �, ����,o�� <br /> � � g-. '� � ,� Posi offce soX 66 <br /> ;�� �'�_I � ` `� ('j Crystal Bay,Vlinnesota 55323-OOG6 <br /> \���kESH�4� <br /> �,_—�= <br /> DATA PRIVACY ADVI.SORY <br /> In accordance with M.S. 13.04, Subd. 2, "Riahts of subjects ot data", �ve would like to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private ar confidential information. <br /> You are notified that: <br /> 1. 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 /> pernit or �icense. <br /> 3. The information may be shared with other local, state or federal a�encies to the <br /> extent necessary to p:ocess tri,: permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> inf�ormation may become punlic. <br /> �. You have certain ri�hts under M.S. 13.04 (see fo�lowinQ paQe) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> �-r��`�i� -�o�� -�S l�e ►f'`_ <br /> First Middle Last <br /> ?� — �'l c� � ►� � � � r�i� ��-�-. <br /> Address <br /> �v �, �� ��� ���� s�-'3 � �- -- � c� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> �� <br /> Sianature <br /> v TELEPHO!V�E-473-7357� FAX-473-0510 <br /> 10 <br />