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CITY of ORONO <br /> Poet Oftice Box 66•Cryatal Bay.Minnesota b5323•Municipal Officee <br /> • <br /> � . � � On the North Shore of�ake Minrtetonka <br /> DATA PRIVACY ADVISORY <br /> In accordahce with M.S. 13.04, Subd. 2, "Riqhts of sub jects of <br /> data", we would like to inform you that your r�quest for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to furnigh certain private or con�idential 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 /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. Th� information may be sri�red with other local, state or <br /> federal agencies to the extent necessary to process the permit or <br /> licet�se. <br /> 4. If your requested permit or Iicense requires Council action <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 process this apglication or <br /> permit. <br /> � ��� ���� ���r� <br /> First Middle Last <br /> ���0 Z,.I�C.t�l.l� �I� �"" ��c7 <br /> Address <br /> ��i�7�t�-�f�'� 1�'�fJ �a���f";� <br /> City State Zip <br /> _ �� �� ��� <br /> Phone' <br /> I understand my ri ts tat d bove. <br /> � <br /> Sig � <br /> BUILDINC�t.ZONiMG—473-7357 • ADMWISTRATION�FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSINC <br />