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Municipal Offices <br />Post Office Box 66 <br />Crystal Bay, Minnesota 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 fu_rnish certain private or confidential information. <br />You are notified that: <br />1. <br />,., <br />-'-• <br />3. <br />4. <br />5 . <br />6 . <br />The information you furnish will be used to determine your qualification for the <br />permit or license requested. <br />You may refuse to supply data, but refusal may require that the City deny the permit <br />or license. <br />The information may be shared with other local, state or federal agencies to the extent <br />necessary to process the permit or license . <br />If your requested permit or license requires Council action to approve, some <br />information may become public . <br />You have certain rights under M.S . 13.04 (see following page) to review private data <br />on yourself. <br />Your full name is required to process this application or permit. <br />First Middle <br />Pr, <br />Last <br />I S;Jo <br />Address <br />City State <br />I understand my rights as stated above. <br />Sign~('. <br />TELEPHONE -411}7357 • FAX· 473--0510 <br />Zip <br />W ~5116-51/'llJ <br />Ji ,, '-/7 /-7S-8' ) <br />Phone