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crrYof cmoNO <br />Municipal Offices <br />Street Address: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />Mailing Address: <br />P.O. Box 66 <br />Crystal Bay, MN 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. <br />6. <br />You have certain rights under M.S. 13.04 to review private data on yourself. <br />Your full name is required to process this application or permit. <br />1\\cM£b <br />First <br />CMUSo/^ <br />Middle Last <br />iY\ a! / <br />City State <br />(ie H0>A-(^O <br />Phone <br />I understand my rights as stated above. <br />Tdei «U)473>7357 • FAX 4734510