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i <br /> �• � . .. � <br /> CITY of ORON <br /> Post Office Box 66•Cryetal BaY,Minnesota 55323•Municipal Offices <br /> •. <br /> o - • • � On. the North Shore of Lake Minrcetonka <br /> DAT�_�R�VACY AD�SORY -- <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> 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 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 other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. you have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name. and date of birth are required to process <br /> this application or permit. <br /> � ��� ��� � <br /> - - --- - --�-� - <br /> . .------------- -----.. <br /> _ .. . .------- ----�_._ .._.__..-----.. ---�---�- � Last <br /> First Middle <br /> 3 —1 �G� S`n �`lv�� � <br /> �Address .Z <br /> ��� -- -- - --�------..___S <br /> --- --��- <br /> - ---. .._. S�-_. y�— -.--- ...-.-.-- --�--. _ . <br /> ....__. _ --- ---- <br /> City State Zip <br /> � ( r���� ---- - -- - <br /> Phone <br /> I understand my rights as stated above. <br /> C -- - - <br /> Signaturey <br /> BUILIIING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESS2ti G <br />