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VITYof ORONO <br />Post Ofte Bo: 66 • Crystal Bay, Miaossots 55= • Maaicipal Offim <br />On the North Shore of Lake Minnetonka <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of 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 dt:partments 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 otter local, state <br />or federal agencies to the extent necessary to process <br />the permit license. <br />4. If your requested permit or license requires Council <br />action to approve, some information may become public. <br />5. You have certian rights under M.S. 15.165 to review <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 <br />V (; q <br />A r� � <br />O <br />Middle <br />�It41-1 <br />s <br />Date o birth (does not apply to building/general permits) <br />r � r <br />Phone <br />I unde t d my rights as stated above. <br />X <br />d�j �• <br />Signa,Ure <br />WIL DIN(: • ZONUV(: — 47 3-713 7 • ADmrd1STttAT10% & FINA.rCt: — 473.7332 • PUBLIC WORKS — 473.1359 <br />k. SF-W%G <br />