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,7i. <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � - � s On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , s�a�e or <br /> federal agencies to the extent necessary to process the permit or <br /> I.icense. <br /> 4. If your requested permit or I.icense requires Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � � �T o,�,��— <br /> �1�'►n <br /> First Middle Last <br /> ��S� r�.�l.��C�D� ��/,,C. N. <br /> Address �� <br /> I�R�v,��s/� C,�,��,C.c , �� . �s 5�3D <br /> City State Zip <br /> s�� - 9��/ <br /> Phone <br /> I understand my rights as stated above. <br /> � � <br /> Signature . <br /> BUILDING&ZOlY1NG—473-7357 • ADMINISTRATIOIY&.F[NANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />