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. <br /> ` � <br /> � <br /> � <br /> -.�. - <br /> '�� .�-� �` <br /> � � � � �` '��' O� �1�ON0 <br /> �.� �I <br /> . .���� <br /> - �,�,r�;.; Post Office Box 66•Crystal Bay, Minnesota 55323•Muniripal Offices <br /> ! <br /> � _ � � 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 like to inform you that your request for a pe�q i�e <br /> Iicense from the City of Orono or any of its departments may <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish wil.l be used to determine your <br /> qualification for the permit or Iicense 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 oth��r e scthe permit or <br /> federal agencies to the extent necessary to p <br /> Iicense. <br /> 4. If your requested permit or 3icense u�qic res Councii ac�ior. <br /> to approve, some information may become p <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 proc�ss this application or <br /> permit. <br /> :, , ^ <br /> i� �^���� '" ,� �f� � ,(�� � , � `��, _ �.. <br /> f� <br /> Mic�dle � Las}t <br /> First i � <br /> �' (� - i �v'J✓ �'� � <br /> Add ess <br /> � <br /> , , ; 1,��, <<��-� < <��� <br /> ; <br /> ��� ������ � �� r� ; � � <br /> City State Z1p � <br /> � � � � � � <br /> Phone <br /> I understand my rights as stated above. <br /> , <br /> ;' � _ _--� <br /> ) <br /> , �-_ - <br /> , �� =L �-�- _--�-_: <br /> S i atur�- "� � <br /> •� • PUBLIC WORKS —473-7359 <br /> BUILDING&ZONING—473-7357 � ADMINISTRATION&FINANCE—473-7358 <br /> ASSESSING <br />