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40 v , <br /> 0 <br /> r CITY of ORONO <br /> 1 I li ; ;� ��, Municipal Offices <br /> Mailing Address: <br /> \v =1 rr„ �G Street Address: <br /> Hpg' 2750 Kelley Parkway P.O. Box 66 <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 <br /> to inform you that your request for a permit or license from the City of Orono or any of its <br /> ,r— \e, <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 <br /> permit or license. h... .,. <br /> a <br /> ,,, <br /> ,., <br /> 3. The information may be shared with other local, 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 z;-r'' <br /> information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private '` R. <br /> data on yourself. "" <br /> 6. Your full name is required to process this application or permit. <br /> A)-ex.oid-ev- La,i1 70hio51 <br /> Firstcer.r,c ,Middle .—L st <br /> O 1 ns-f-o) 4:4:k <br /> (Igo 5. PYDurn fro <br /> Address <br /> ZalA- MN 5-S-3q/ wq'gq 3 <br /> City al State Zip Phone <br /> I understand my .ghts as -d ab -. <br /> SignatureC d ,0041,Prr,),-u <br /> L___ e <br /> Telephone (612) 473-7357 • FAX 473-0510 <br />