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(�JTY of ORONO <br /> Post Office Box 66•Costal Bay,Minnesota 55323•Municipal Offices <br /> 8 <br /> On the North Shore of LakeMinnetonka <br /> DATA_PRIVAC`I ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request fpr a permit <br /> or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential inform tion. <br /> You are notified that: <br /> 1. The information you furnish will befused to determine your <br /> qualification for the permit or license r�qu <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 withjother local , rmit or or <br /> federal agencies to the extent necessary too process p. <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. 1.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth ire required to process <br /> this application or permit. <br /> First Middle <br /> Address <br /> City State Zi <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING 1 <br /> 5 <br /> I <br />