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CITYofORONO <br /> Municipal Offices <br /> f� s ti , Office Box 66 <br /> _ <br /> s�: <br /> \•tt fr to ;•i1;., �4�r �� Post Crystal Bay,Minnesota 55323-0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like 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 your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve. some <br /> information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRLNT <br /> 4J�5 � s� c' ci <br /> �a`i ` (Si ` I It`rA_ L <br /> First Middle� � Last <br /> 3024,2 a,77,0-744) 6-40 <br /> Address <br /> ilia. <br /> " / A ) 3c' /J-*7 <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> 3/ Df .. <br /> Signature <br /> TELEPHONE-473-7357• FAX-473-0510 <br /> 10 <br />