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CITYof ORONO <br />Municipal Offices <br />Post Office Box 66 <br />Crystal Bay, Minnesota 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 pennit 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 pennit or license. <br />4. If your requested pennit or license requires Council action to approve, some <br />information may become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />First <br />Jo..~s= L;(;~r(A_;(.ff <br />Middle Last <br />G~vl-lu_~ <br />Address <br />0 V-U\A..0 0?>'1/ <br />City State Zip <br />I understand my rights as stated above. <br />--- <br />TELEPHONE -483-7357 • FAX -473-0510