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CITY of ORONO <br />Municipal Offices <br />Street Address: Malling 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 />y OU 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 />.., <br />.) . The information may be shared with · other locat state or federal agencies to the <br />extent necessary to process th~ permit or license. · · · f .~. ~ <br />~~:~?~ <br />If your requested permit or license requires Council action . to approve, some=" .4. <br />information may become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review private <br />on yourself. <br />6. . Your full name is r~quired to pmcess this application or permit. <br />/'.:-:,~"',~, Lt'.,'\\ <br />_...:.G.;::;r...:.a"""'y...:.d:....;;o...:.n:;__ ____ --=K~. -------=N=e=w....,,m=a=n._.,---"J""'r'-'.'------------f\fc1 ~ ··,1 <br />First Middle Last '~ "~ :"·, <br />1655 Bohn's Point Road <br />Address <br />Orono MN 55391 <br />City State Zip <br />I understan71i2f;::: <br />SignaturP <br />Telephone (612) 473-7357 • FAX 473-0510 <br />10 <br />471-8791 <br />Phone