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DAV PRIVACY ADIRILORy <br /> M accordance with Minnesota State Statute 13.04 Rights of Subleas of Data,Subd.2,"Terxlerrson warning".we <br /> would Me to inform you that your request for a permit or license from the City of Orono or any of ite departments <br /> inlay require you to Furnish certain private or conNdenWl Information. <br /> You we notified that <br /> 1. The Information you furnish will be used to determine your qualificallon for the permit or Oconee <br /> 2. You may refuse to supply data,but refusal may require that the City deny the permit or Oconee. <br /> 3. The informa3on may be shared with other looa else or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or Hoense requires Council action to approve, some infonne#bn may <br /> become public. <br /> 5. You heye eeraln rights under Minnesota State Statute 13.04(see fdlowing paps)to review privets <br /> data on yolrrself. <br /> 6. Your full name is required to process this application or permit. <br /> JUSTIN MICHEAL O'NEAL <br /> First Middle Last <br /> PO BOX 881 <br /> Address <br /> ST CLOUD MN 58302 320 252 9400 <br /> City Stele Zip Phone <br /> I understand my rights stated above. <br /> RECEIVED <br /> %w ince pppMcelbn Alit'2015 <br /> OCT 14 2016 <br /> Pa.'°t0 # 3 8 7 9 SOF ORONO <br />