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`i&* <br />CITY of ORONO <br />P)%t ()ff"ice lik,x 660Cry%tal Bay, Minnesota W2-3•Municipal Offices <br />On the North 5hor,• of Lake 3finnetortka <br />U1I, _ _RR.JVACY_ ADV.ZSORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", we <br />would like to inform you that your request for a permit or license <br />from the City of Orono or any of its departments may require you to <br />furnish certain private or confidential information. <br />You are notified that: <br />1. The information you furnish will be used to determine your <br />qualification for the permit or license requested. <br />2. You may refuse to supply data, but refusal riay r. .-quire that <br />the City deny the permit or license. <br />3. The information may be shared with other local, state or <br />federal agencies to the extent necessary to process the permit or <br />license. <br />4. If your requested permit or license requires Council ac-'_.on <br />to approve, some information may become public. <br />5. You have certain rights under M.S. 15.165 to review private <br />data on yourself. <br />6. Your full name, and date of birth are required to pro^ess <br />this application or permit. <br />First V Middle Last <br />P0. eon sgp _ <br />Address <br />E Yet1r%o YVLA 5533 ! <br />city State Zip <br />3j9 - 067� <br />Phone ~ �' <br />I understand my rights as stated above. <br />qnatu <br />�-� PIle- *1 <br />BUKA)WG a ZONWG - 47 )a )3 7 <br />ADM L%1$TRAnON 4 FINANC'F -- 47l 7154 0 YI 8, K WORKS - 471-7159 <br />