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CITY of ORONO <br />Municipal Offices <br />Street Address: <br />2750 Kelley Parkway · <br />Orono, MN 55356 <br />· DATA 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 />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 />3. · The information may be shared with · other lo cat 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 data <br />on yourself. <br />6. Your full name is required to process this application or permit. <br />Jk;as-h~i f()hL · <br />First . I . Middle Last <br />I 6 .36 /llr-#rr ?4, .De,. <br />Address· {/ <br />. !1)4?ftt.· <dx~. <br />City .. <br />·¼//L <br />State <br />S-Ssl/ L/76~~~~ <br />Zip Phone <br />I undersiand my rights~. ted abo. ve. · ~.~,c~ <br />Signature <br />Telephone (612) 473-7357 • FAX 473-0510 <br />10