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CITY of ORONO <br />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 furnish certain private or confidential information. <br />You are notified that: <br />1. <br />' <br />,., <br />.) . <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 reqmres 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 Last =- <br />Address <br />tttv (£ill\ L(:73-Lc3~i:t_ <br />State Zip Phone <br />I understand my rights as stated above. <br />~~~J <br />Signature <br />TELEPHONE -4!S7357 • FAX -473-0510