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CITY of ORONO <br />Municipal Offices <br />Street Address: Mailing Address: <br />P.O . Box 66 2750 Kelley Parkway <br />Orono, MN 55356 Crystal Bay, MN 55323-0066 <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd . 2, "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 />2 . You may refuse to supply data, but refusal may require that the City deny the permit <br />or license. <br />~ ~1 f <br />3. <br />,._,~t,t);;,t <br />-,;/"; r ' g The information may be shared with other local, state or federal agencies to the ,'f>~ ~ · <br />4 . <br />5 . <br />::::u:e:::::: ::::• ::e !::::: :::::::eCouncil action to approve, some (lf) <br />information may become public . ~, iJ <br />"DF! :.":·J <br />You have certain rights under M.S . 13 .04 (see following page) to review private data '-<\,J. <br />on yourself ' ' <br />6. Your full name is required to process this application or permit. <br />·Yrerrt Al-er V fezaJ el( <br />First Middle Last <br />J,)'QD &i vs:Je Ji <br />Address <br />{}ro;10 <br />City <br />11/ 1 <br />State <br />.5SJ.J& ,Jt;t/~~~ <br />Zip Phone <br />9 <br />Telephone (612) 473-7357 • FAX 473-0510