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02/17/20 □3 15:06 551-541-::tl427 <br />CITY of ORONO <br />Strut Addr11s: <br />2750 Kelley Parkway <br />Oronll, MN 55356 <br />Municipal Offices <br />P._ATA PRIVACY ADVISORY <br />11111111 Address: <br />P.O. Box 66 <br />Crystal Bay, MN 55323-0066 <br />In accordance with M.S. 13.04 1 Subd. 2, "Rights of subjects of data1 <br />'; we would like to <br />inform you that your request for a pem1it or license from the City of Orono or any of its <br />departments may require you to furnish certain private or confidential infonnation. <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 pennlt <br />or license. <br />3. <br />4. <br />s. <br />6. <br />The information may be shared with other local, state or federal agencies to the <br />extent necessary to process the pennit or license. <br />If Your requested permit or license requires Council action to approve, some <br />infonnation may become public. <br />You have certain rights under M.S. 13.04 (see following page) to review private data <br />on yourself. <br />Your full name is required to process this application or pennit. <br />5~~~~ <br />First Middle · Last <br />~\31l'lo ~~l.J)\.)Q_ ~\\~¥:- <br />Address <br />O~o~, <br />City 7 State Zip <br />C\~ -~rn--)a~1 <br />Phone <br />I understand my rights as stated above . <br />. ~ Wf'~ ~,, ~½-S ~ <br />Si~ature "' <br />Sec.13.04 RIGHTS OF StJBJECTS OF DATA <br />Subdivision 1. Type or data. The rights of individual on whom the data is stored or <br />Telephone (952) 24!)..4.600 • Fn (952) 2-49~1, <br />www.d.cgono.mn.~--- <br />(:~·-·-,--< ~~\ <br />\~.:.: .,.{,/