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�4�� <br />CITE" of ORONO <br />Munid* offices <br />Past office Box 66 <br />crystal Bay, NUnnesota : -323•-0066 <br />DATA -PRIVACY ADVISORY <br />In accordance with 1f.S. 13.04, Subd. ?, Rights of subjects of data", we would like to <br />inform you that your request for a permit or Iicense from the City of Orono or any of its <br />departments may rrequire you to furnish certain private or coruzdential 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 />nit <br />=. You may refuse to supply data, but refusal may require that the City deny the pei <br />or license. <br />. The information may be shared with other local, state or federal agencies to the extent <br />necessary to process the permit or license. <br />If your requested permit or license requires Council action to approve, some <br />information may become public. <br />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 />P—D 8 C—gT jV1 c C(Jl1/e5 <br />First Middle Last <br />Z/So Sr-,I6VI-1N RlV4�5 <br />:,ddress (/./) 1/73 32Y6 <br />D AD O %'� r� /V ESt) %?4 SS 39 / (kV) a g 7 5-200 <br />City St`te Zip Phone <br />I understand my nghLs as stated above. <br />Signature <br />P 67 : 1 y 7 3 SAY ,21DGF X04 D <br />TEI F MONNE - 41:97357 9 EAX - 47--0510 <br />