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-�' ' <br /> �-_� , <br /> � � � <br /> O = _ - O �� <br /> C�T�' o� (�R� <br /> +� ';:��- _ �, ,f��o� <br /> r�' :; ! . Fy Past Q�ce Box 66 <br /> �� - ^ '�� -- � G�' Crystal Bay,`tinnesota�5323-4066 <br /> .;1.. - �. <br /> ��kESK��� <br /> � <br /> DATa PRIVaCY ADVISORY <br /> In accordance «�ith �i.S. 13.04, Subd. ?. "Ri�hts of subjects oT data". we would li�e to <br /> inform ��ou that your request ior a p�rr.zit or license irom the Ciry or Orono or any of its <br /> departments may require ��ou to rurnisn c�rtain pri��a�e or confidential irLformation. <br /> You are notified that: <br /> 1. The info�nation ��ou rs:nish «�ill be used to determine ;�our qualification for the <br /> permit or license requested. <br /> 2. You may refuse to suppl}' data, but refusal may require that the Ciry der.y the <br /> perrnit ar �icense. <br /> 3. The information may be shared «�ith other local, state or federal aaencies to t},e <br /> extent necessar}� to pro�ess ��.e �e:r��t or licer.se. <br /> =�. If ��our requested pe:mit or license requires Council actior. to approve, some <br /> iniormarion mav becom� pubiie. <br /> �, You hav� ce�ain ri�hts unde: �I.S. 13.04 (se� fo?lo�z7in� p�a�j to review private <br /> data on ��ourself. <br /> (, Your full name is required to process this application or permit. <br /> PLE.��E PRL�'T <br /> ��� P� �. Lt;n� ��_��v� <br /> First �liddle I�st <br /> � � � ��� � � <br /> ,-�ddress <br /> �.C.��S' �� ��_______�'l•..o � —.�� ;/ [-1'�7 �/���.� L— <br /> Cit;,l Stace Zip Phone <br /> I ""d re stand � ria ts as `taced ove. <br /> � <br /> � \�� ` <br /> re <br /> y � TEI.EPHO?YE-�i73-7357• FAX-�3'T3-Q�10 <br />