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CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal*ces <br /> On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> in accordance with M.S. 13.04, Subd. 2, "Rights subjectsof ermit or <br /> data", we would like to inform you that your request permit <br /> license from the City of Orono or anfor <br /> of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you fit or Ii cense ill be used re quested, determine your <br /> qualification for the perm <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 local, state or I <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 1 <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 application or <br /> permit. <br /> t Middle <br /> Last <br /> Firs <br /> Address ra <br /> o <br /> ity State Zip <br /> q7o_ g7 � � <br /> Phone <br /> I understand my' . fights as s at above. <br /> Signature ,J <br /> • <br /> ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7 35 9 <br /> BUILDING&ZONING—473-7357 <br /> ASSESSING <br />