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CITY of ORONO <br />Municipal Offices <br />Street Address: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />DAT A PRIVACY ADVISORY <br />Mailing Address: <br />P.O . Box 66 <br />Crystal Bay, MN 55323 -0066 <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 ce1iain 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 permit <br />or license. <br />3. The information may be shared with other local , state or federal agencies to the <br />extent necessary to process the pem1it or license. <br />4. If your requested permit 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 data <br />on yourself. <br />6. Your full name is required to process this application or permit. <br />-Pt1:, LL IP CEo R.C-E.. /Y] A &T t rJ <br />First Middle Last <br />12-30 <br />Address <br />rvirJ 95 ?,. -'--/ 7 5 -63 I'-( <br />City State Phone <br />I ri't my &m;;:· <br />Signature ¥ <br />Telephone (612) 249-4600 • Fax (612) 249-4616 9