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02/17/2003 15:05 551-541-tNT/ <br />CITY of ORONO <br />Strut Addl'l1SJ <br />2750 Kelley P1~way <br />Orona, MN 55356 <br />Municipal ot1kes <br />PAIA PRIVACY ADVISORY <br />11111111 Address: <br />P.O. 8ox 66 <br />Crystal Bay, MN <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data11 <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 />y OU are notified that: <br />1. The infonnation you furnish will be used to detennine 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 pennit <br />or license. <br />3. The infonnation may be shared with other local, state or federal agencies to the <br />extent necessary to process the pennit or license, <br />4. lf Your requested pennit or license requires Council action to approve, some <br />infonnation may become public. <br />S. 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 pennit. <br />First Middle Last <br />Address <br />C\ ~ ---~f\'\--'a~1 <br />State Zip Phone <br />I understand my rights as stated above . <br />. ~ wre\~ ~ -~ ~~-;; ~ <br />Si~ature " <br />Sec.13.04 RIGHTS OF SUBJECTS OF DATA <br />Subdivision 1. Type of data. The rights of individual on whom the data is stored or <br />Teltpbone (952) 249-4fi00 • Fax (952) 249--461, <br />www.d.cgono.mn.us