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� <br /> . (' <br /> r - � <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal BaY,Minnesota 55323•Municipai 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 permit or <br /> license f rom 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 license requested. <br /> .�,, '�'',�'' �R'"JT�YTi3 <br /> 2. You may refuse to supply da�a�, b��-�#�}�� �aY require that <br /> the City deny the permit or license. ,;:v,y;�fh1 <br /> 3. The information may be shared with other local, s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac�ion <br /> to approve, some information may become public. <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 procsss this application or <br /> permit. <br /> First Middl.e Last <br /> 55 <br /> Address <br /> ✓��� <br /> City State Zip <br /> '�"/�(�.'���j - <br /> Phone <br /> I understand my rights as stated above. <br /> Signatu e • <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />