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; � <br /> ��'�'� o� ����T� <br /> M Post Office Box 66•Crystal Bay,Minnesota 55323•Mnnicipal Offices <br /> • <br /> � � � � On the North Shore of Lake Minnetonka <br /> �2�1�� �R� ����g� <br /> In accordance with M.S. 15.I65, "Rights of subjects of data", we <br /> woul.d Iike to inform you that your request for a permit or �icense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidentia� information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qua�ification for the permit or license 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 /> I.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 /> - - ..__ .... ..-- •-- ___ . <br /> -- - ... ._ . ._ _ __ . ._._ .. ._ <br /> First Middle Last <br /> Address <br /> .. ... . . . .. __ . . .._ <br /> -- - -� - .. . ._ <br /> City State Zip _ <br /> � _ - - <br /> Phone • <br /> I understand my rights as stated abvve. <br /> I <br /> Signature <br /> BUII.DtNG�ZONIIVG—473 7357 • ADMIIVISTRATtON�FIIYANCE—473 7358 • PUBLiC wORKS—473-7359 <br /> ASSFSSING <br /> 5 <br />