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� ,r <br /> � / �\ <br /> � � � <br /> , /O - _ O � <br /> =--; � CITY of ORON <br /> ,� � ,�f:�: � � `�,��o� <br /> ,,�� 1, . � Post O�ice Sox 66 <br /> ''�.� '�-� `ti ''� - �•`f ��' Crystal Bay,�tiiu�sota 5a'32.�0066 <br /> '� � .;j.. :-, _� <br /> ' ' `9kESI3a� <br /> ��-. <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. ?, "Rivhts of subjecu c.�T data", we wouid like to <br /> inform you that your request ior a p�rmit or license from the Ciry or O:ono or any of ics <br /> depar�ments may require ��ou co fi:rnish cercain private or co�dential information. <br /> You are notified that: <br /> 1. The information you furnish «�il? be used to determine your qualification for the <br /> permit or licensz requesced. <br /> ?. You may refuse to suppl}� �ata, but refusal may require that the City der.y the <br /> rermit or iicense. <br /> 3. The information may be shared with other local, stace or federal a�encies to tr.e <br /> exter�t necessary to p:���ss �:1� permit or license. <br /> 4. If your requested permit or Iicense requires Council action to approve, same <br /> information may becom� public. <br /> �. You hav� ce;:ain ri�hts under M.S. 13.0? (se� fo�lo���ina paQP) to review privare <br /> data on yourself. <br /> 6, Your full name is required to process this application or permit. <br /> PLEASE PRLNT <br /> S <br /> �U� c � �do,� <br /> Firsc �iidd:e Last <br /> � D <br /> �ddress <br /> D U?/ 1� /l/ �53� 7 2. - �Y <br /> Ciry <br /> State Zip Phone <br /> I understand my riahts as stated above. <br /> i ature <br /> ���orrE-a�-�s�• Fax-a�-osio <br />