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,- _ <br /> A_ <br /> CITY of ORONO <br /> CITY Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> OF <br /> ORONO On the North Shore of Lake Minnetonka <br /> DATA PRIVACY 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 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. The information may be shared with other local , 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 private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> -4921/1 AS 9,9,He P/It,/, ,m,,-,,, <br /> First Middle Last <br /> 3 44 L - e t 'e <br /> Addr s _ <br /> � ''/ii 7( , , . S-5 <br /> City / State Zip <br /> / 7y 1‘.37 v <br /> Phone <br /> I uncle -tand my rights as st . above. <br /> 41111111111111111117 _ - - / <br /> " ignature <br /> BUILDING& ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> e: <br /> E' <br />