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/0 0 ', <br /> , }air t. , <br /> CITY of ORONO <br /> , �� ;, �► �� Municipal Offices <br /> r� tr sr J !� Post Office Box 66 <br /> \ f r ',..t+,..- ��� �/ crystal Bay Minnesota 55323-0066 <br /> ,,,,t',. 3 -A'.4) <br /> 0 <br /> vv��Esi;o� <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 PRINT <br /> be C A L 11'lticu meC_ <br /> First Middle Last <br /> l a i 9 a u3a_Al �— 6\0d <br /> Address <br /> ,3,, „ 3c1 <br /> 4-- -3 -. 6 S- <br /> `Cityty State Zip Phone <br /> I understand my rights as stated above. <br /> , / / . <br /> ` i 0 I li,Ili // 1 I A /,A-A- <br /> rign•t � <br /> ure <br /> TELEPHONE-473-7357• FAX-473-0510 <br /> 10 <br />