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ONO <br /> CITY of U�i <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Mun1c�Pa1 ��� <br /> • <br /> � _ e � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY 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 yerm llire <br /> Iicense from the City of Orono or any of its departments ma req <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 license. <br /> 3. The information may be shared with other local , s�ate or <br /> f ederal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. ac��or. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priv�te <br /> data on yourself. <br /> 6 . Your full name is required to process this a�plication or <br /> permit. <br /> ��-� �f �,��,, �f 1; , J��''� ���=�' �i /�" <br /> " Middle Last <br /> First <br /> � / <br /> /� �� �/ �' ���'� f �� <br /> Address <br /> � >� � 7/ <br /> � ����: � <br /> City State Zip <br /> �� � ��- �r�/ � <br /> Phone <br /> I understand my rights as stated above. <br /> � ' i�� � � <br /> � <br /> Signature ( <br /> �J <br /> BU1LD[NG&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />