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�• ' ' <br /> ��; ^ ��� <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> � <br /> s - � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> Iicense from the City of Orono or any of its departments may require <br /> 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 <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ,�,�--vzo lc:Q � I'�'1 e��.-e l/D % _ <br /> First Middle Last <br /> /3 �� �es � �� � ��. f �i ' rz <br /> Address <br /> �/1/� v w.�.� � � � �3 � �- <br /> City State Zip <br /> �-} � a • C�7 U� <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRATIOIY&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />