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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 c· {~.· . ·: •o::. ~. <br />permit or license requested. . . . -@ '" Jr, <br />2 . You may refuse to supply data, but refusal may require that the City deny the permit <br />or license . <br />3 . <br />4 . <br />The information may be shared with other local, state or federal agencies to the <br />extent necessary to process the permit or license . ~:,;.,-.~-·~i] ' .~\ ~ ~'~j; <br />If your requested permit or license requires Council action to approve, some ~ <br />5. <br />information may become public . CJ. <br />You have certain rights under MS. 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 />S)\'\Y 10 L A1pf?l1AJU L o VE/A-c ~ <br />First Middle Last <br />c3\20 <br />Address <br />!Md \,U 55:?:>0y blzJl12 . 1oqo <br />State Zip Phone <br />I ~and my rights as stated abou ~t <br />Sin <br />9 <br />Telephone (612) 473-7357 • FAX 473-0510