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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 . 15. 165, "Rights of subjects of data" , <br /> 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 <br /> require you to furnish certain private or confidential inform- <br /> ation. <br /> You are notified that: <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested . <br /> 2 . You may refuse to supply data, but refusal may require <br /> that the City deny the permit or license . <br /> 3 . The information may be shared with other local , state <br /> or federal agencies to the extent necessary to process <br /> the permit or license. <br /> 4 . If your requested permit or license reqires council <br /> action to approve, some information may become public. <br /> 5 . You have certian rights under M.S . 15 . 165 to review <br /> private data on yourself . <br /> 6 . Your full name, and date of birth are required to process <br /> this application or permit. <br /> • <br /> First Middle Last <br /> Address <br /> Date of birth (does not apply to building/general permits) <br /> Phone <br /> I understand my rights as stated above. <br /> X • <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />