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\i <br />Lr •jcfr^:^v7 <br />i)R0N05 <br />CITY of ORON( <br />Post Ornce Box 66•Crystal Bay, Minnesota 55323 •Municipal Offi( <br />On the North Shore of Lake Minnetonka <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", we <br />would like to inform you that your request for a permit or license <br />from the City of Orono or any of its departments may require you to <br />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. 15.165 to review private <br />data on yourself. <br />6. Your full name, and date of birth are required to process <br />this application or permit. <br />V7/ ' <br />Phone <br />I understand my rights as stated above. <br />Signi-ture <br />BUILDINC k ZONING - 473-7357 <br />ASSESSING <br />ADMINISTRADON A RNANCE - 473-7358 PUBLIC WORKS - 473-7359 <br />I <br />\ <br />iKirth .urn Atym j j