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� <br /> � O� "� <br /> �� � _ ° \��, oRONo <br /> - ���. C ITY of <br /> ( , :�,�:''� � -. � ri��oe� <br /> �, ��'� �l�r L�+,�i <br /> \� , � Posc office Box 66 <br /> ,� 1� �'' 1�; '�� Gti� cry,�B�y,�v��s�z3� <br /> ���:�:y;r.. <br /> l '' -'"`��''_,�' 4, , <br /> \��k'ES�1���'� / <br /> ��� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, c�aetfr ms the Citylof Oro oe or�ana lo e ts <br /> inform you that your request for a permit or li <br /> deparunents may require you to furnish certain private or co�dential 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 requesced. <br /> �. 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 aQencies 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 cenain rights under M.S. 13.04 (see followin� paae) to review private <br /> data on yourself. <br /> (. Your full name is required to process this application or permit. <br /> RL1'T � <br /> PLEASE <br /> __._.., <br /> lJt � �i ��- � �� <br /> First Middle Last <br /> (� �l� � t' r Y\1 (�'� � <br /> C.�n cr� <br /> Address <br /> � ���� � <br /> ���-1 � - �-�-�� 2�� <br /> Cirv <br /> State Zip Phone <br /> I und sta d my ri as s above. '�� <br /> i <br /> � � <br /> SiQnature �, <br /> TELEPHO?YE-473-7357• Fa.Y-d73-0510 <br /> 10 <br />