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CITY of ORONO <br />Street Address: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />Municipal Offices <br />DATA PRIVACY ADVISORY <br />Mailing Address: <br />P.O. Box 66 <br />Crystal Bay, MN 55323-0066 <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 />3. The information may be shared with other local, state or federal agencies to the <br />extent 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 />5. 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 />:Cr.r~s A kw e ~cc ~~ <br />First Middle Last <br />1-U.S: bo..,"' {, L u) OL <br />Address \ <br />~ \"{\ SS't5\\ qsz... L\t\\ os~ <br />City State Zip Phone <br />I underntan~o~ <br />Signature # 4 <br />Telephone (612) 249-4600 • Fax (612) 249-4616 9