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. � <br /> I . , � <br /> . � <br /> � � <br /> CITY of ORON4 <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <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 wou3d Iike to inform you that your request for a permit or <br /> Zicense 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 /> gualification 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 Counci� action <br /> to approve, some information may become public. . <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�e <br /> data on yourself. <br /> 6. Yaur ful.l name is required to process this applicatian o� <br /> permit. <br /> l' �� <br /> First Middle Last <br /> 4� � <br /> Ad ress <br /> . � �� <br /> 11 L . <br /> City State Zip <br /> �7� -- �9�`� <br /> Phone <br /> I un rstand my r' ghts as stated above. <br /> Sig ture <br /> BUILDING&ZON[NG—473-7357 • ADMIIVISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING ° <br /> i <br /> I <br />