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� io�_ <br /> O . O <br /> CITYof ORONO <br /> �+ i1'1WidPW ole <br /> Past Office sox 66 <br /> C) Crystal Bay,'. humota 55323-0066 <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require 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 qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the <br /> extent necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> irst Middle Last <br /> Address <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> -V <br /> Signature <br /> TELEPHONE-473-7357•FAX-473-0510 <br /> 10 <br />