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, CITY of ORONO _: <br />Street Address: <br />2750 Kelley Parkway · <br />. . Orono, MN 55356 <br />Municipal Offices <br />· DATA PRIVACY ADVISORY <br />Malllnr 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 <lat~", we would like to <br />inform you that your request for a pemiit or license from the City _-of Orono· or any of its <br />departments may r~quirn you to furnish certain private or confidential information. <br />y OU af e notified that: ... ' <br />1. The . information you furnish will be used to determin~ 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 />,., ., . <br />or ·license. · · · <br />The information may be shared with · other locat state or . federal agencies to the <br />extent necessary to process the permit or license.· <br />4. If your requested permit or license reqmres 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 i; r6qu~ed to process this application or pemiit. <br />Middle · Last <br />Address · <br />. trlr1 L ~5;?) ¢73 -fs-,;;z..y <br />State Zip . Phone <br />I understand my rights as stated above. <br />Telephone (612) 473-7357 • FAX 473-0510 <br />10