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`4kESIH0 . <br />CITY ®f ORONO <br />Municipal Offim <br />Posy otam Box 66 <br />crystal Bay, Nunnesota 5323-0066 <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. ?. "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 certain 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 />You may refuse to supply data, but refusal may require that the City deny the permit <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 />4. If your requested permit or license requires Council action to approve, some <br />information may become public. <br />�. You have certain rights under 1NI.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 />//OAA <br />First <br />2 1 So <br />Address <br />Up�1. <br />City <br />Po13C-9T /M C--CvN45 <br />Middle <br />Last <br />DRl V4!5 <br />y� j W A/jrSvTA S'Y3g/ <br />I understand my rights as stated above. <br />State Gip <br />Signature <br />� y-7 3 8,4y p-j Ds46r ,-04 4D <br />TELEMONE — 411G n57 • EkX - 473-0510 <br />(y) y73 324130 <br />w) a J37 szdO <br />Phone <br />