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.� <br /> i <br /> �---_ <br /> �--__-, <br /> % O�, <br /> � <br /> O O` <br /> :�.�, _ CITY of 4RON0 <br /> �, �, t, ... � rt��o� <br /> � a �'--. � ��� ,� � Post OfSce Box 66 <br /> '��.....,� �� � f� -��+�r G .� CI'VSY�B3V,�'ilI1IlfSOf3 J$�2.3-�6 <br /> ��\ ,J <br /> kESH��� � � <br /> ,_ <br /> DATA PRIVACY ADVLSORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", ���e would lil:e to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine vour qualification for the <br /> permit or license requested. <br /> 2. You may refuse to suppl}� data, but refusal may require that the Ciry deny the <br /> pernit or license. <br /> 3. The information may be shared with other local, state or federal aaencies to tr:e <br /> extent necessary to process tr��. permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> information may become puolic. <br /> �. You ha��e cer�ain riRrts under M.S. 13.04 (see following paQe) to review priva�e <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL\'T <br /> � �, �Y t�Cu� <br /> �d��.� �����,�.-� S <br /> First Middle Last <br /> < � _� ��,.��.--� ��-��►�c°.� `JJ/2 � <br /> � 4 <br /> Address <br /> �/►2�� �` i �� � :� �� � ���—� ��� <br /> City State Zip Phone � <br /> y� r - � �-� l._-- <br /> I un rstand my riQhts as staced above. <br /> Siana " � <br /> ` T'EI.EPHON�—473-7357� FAX-a73-0510 <br /> 10 <br />