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CITY of ORONO <br />Street Address: <br />2750 Kelley Parkway <br />Orono, MN 55356 <br />Municipal Offices <br />DAT A PRIVACY ADVISORY <br />Malling 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 />I. 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 <br />permit 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 <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />First Middle Last <br />[520 <br />Address ( 'fS2.) <br />SS3~/ 471 t7T72- <br />City State Zip Phone <br />I understand~d above . <br />Signature ~-~---~ <br />7 <br />Telephone (612) 249-4600 • Fax (612) 249-4616 <br />' I