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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 />Mailing Address: <br />P.O. Box 66 <br />Crystal Bay, MN 55323-0066 <br />In w:cordance wilh M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform <br />you that your request for a permit or license from the City of Orono or any of its departments may <br />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 locai, stale 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 />Ct+f.\ <br />First <br />l 2-,D <br />Address <br />1.-o NOJ <br />City <br />--Signature <br />I '< VivVJ~Gt:..,,~1,.~o <br />Middle Last <br />5 OJ 71.,~ t>rl-01.,ur-> ~o/\-,D <br />Lt~~~ lV10 953¼ <br />State Zip <br />Telephone (612) 473-7357 • FAX 473-0510 <br />16 <br />6-, I 2 --L( 7 3 / O 8 2 )- <br />Phone