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_. � <br /> � .�� <br /> � ' <br /> � �ITY of U�iONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Mnnicipsl Officea <br /> • <br /> � � � A � On the North Shore of Lake Minnetonka <br /> -- <br /> DATA_ �RIVACY �DVV�SORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> 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 Iicense. <br /> 3. The information may be shared with other Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> ;�t�1��Q ��� ��L�'`f . .----�---�--- --- .- <br /> First Middle Last <br /> �fi�'_ _ /V. ���-�=-_..�__------.---_. .._. --- .. _ _ ---- . _. . -- --- <br /> Address <br /> �.�� ��,�./ �-��� 1 _ _ - - -- - <br /> �, City State Z1p <br /> ���' � D�O� -- - -- -- . <br /> Phone <br /> I understand my rights as stated above. <br /> � � --�----- - ----� ----------- <br /> Signature <br /> BUILDING&ZON[NG-473-7357 • ADMINISTRA770N&FINANCE-473 7358 • PUBLIC WORKS-473-'I359 <br /> ASSESSI\C <br />