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CITY of ORONO <br />1'(mt OMee Bo= 660Crystal Ray, MinnewAa 5,53M * Municipal Officer <br />On the North Shore of Lake Minnetonka <br />DATA PRIVACY ADVISORY <br />_.. ..�cordance with M.S. 15.165, "Rights of subjec e^ �F data", <br />we would like to inform you that your request for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are notified that: <br />1. The information you furnish will be used to determine <br />your qualification for the permit or license requested. <br />2. You may refuse to supply data, but refusal may require <br />that the City deny the permit or license. <br />3. The information may be shared with other local, state <br />or federal agencies to the extent necessary to process <br />the permit or license. <br />4. If your requested permit or license regires council <br />action to approve, some information may become public. <br />5. You have certian rights under M.S. 15.165 to re,,iew <br />private data on yourself. <br />6. Your full name, and date of birth are required to process <br />this application or permit. <br />First Mi Last <br />'r/C j z� � Js. 0, ZZ l <br />Address <br />Date of birth <br />Phone <br />I understpnd my rights as stated above. <br />X <br />WILDING a AAWM-FA7 • MMIINISMATIO1N • F1%001 - 47173311 0 Pt Mt 1t 164 MKS - 471.7359 <br />AW &M%4; <br />