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�°� <br /> 0 0 . <br /> � , . ,�:.Ty � CITY of ORONO <br /> I\���1�, ��i� v,� ,,�E�,�`.,�� !�r Municipal Offices <br /> � � „ ; . � <br /> ti <br /> ,� �:�� �-`���,�G Street Address: Mailing Address: <br /> '��HQg' 2750 Kelley Parkway P.O. Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323-0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br /> to inform you that your request for a pernut or license from the City of Orono or any of its <br /> departments may require 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 qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. . <br /> 5. You ha.ve certain rights under M.S. 13.04 (see following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or pernut. <br /> First Middle Last <br /> Address <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> 7 <br /> Telephone (612) 473-7357 • FAX 473-0510 <br />