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� <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> � <br /> a • � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 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 wi3.I 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 license. <br /> 3. The information may be shared with other 3.ocal, state or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <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. 13.04 to review privat� <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> . <<� _ <br /> irst Middle Last <br /> �� �(��,��- S�_ <br /> Address <br /> �j�e.���,�r �l�(.Jll ��1 <br /> City State Zip <br /> `-i?�-f-���- <br /> Phone <br /> I understand my rights a stated above. � <br /> � <br /> , <br /> � <br /> Signature � <br /> ( <br /> � <br /> BUILDING&ZONING-473-7357 • ADMIIVISTRATION.t FINANCE-473-7358 • PUBLIC WORKS-473-7359 � <br /> ASSESSING i <br />