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��y. y; tY i} <br /> ��� j <br /> t„,s�.. ' t��C f�' <br /> �� ��� r��I ��� CITY of ORONO <br /> ��e� . <br /> � � rz <br /> �� �.� <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> s ' • • 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 permit or <br /> license 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 /> qualification for the permit or Iicense reguested. <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 I.icense requires Council action <br /> to ap�rove, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � ._I <br /> �)C�me S � ) / i z � n� <br /> First Middle Last <br /> �`� ( � � � .�L' L ��- <br /> Address <br /> � <br /> � �-,�,�� � U l� /�'1 �J �� :�� �, <br /> City State Zip <br /> `�" �G ��/ L `� Z_ <br /> Phone <br /> I understand my rights as stated above. <br /> ! � <br /> �-- <br /> / <br /> ' Signatur • <br /> �'��.,/ <br /> BUILDING&ZOMNG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING - <br />