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� 22�17�95 17:l]9 THE C I TY OF OROhJO 61 c-47,a-7?57 bN2 <br />', <br /> CI'�Y o:� t)RUN(� <br /> Post O[fice 13ox l3t3•Crystal IIay,Minncciukt.r+Fi3�•Muni�ipel�ffiee�! <br /> • <br /> � � � UR the North �Sh�re oF Lake Min�cetonka <br /> DATA PRTVACY 14DVISQRY <br /> xn accordance wi�h M.S. �3.04 ► Subd. 2� "R�ghts of subjec�s of <br /> data",: we would like to inform You that your rear�men� r�$P�r� lxe <br /> iicense f xom the City of Orono ox any df its dep y q <br /> i �ou to furn�sh certiaxn �xiva�e or confidentia�. in�ormation. <br />� You are notified that: <br /> l. The informa�ion y�u fuznish w�ll be used �c determine your <br /> qua�.�.fication for the per�nit er lic�nse xeQuested. <br /> 2. Xou may refuB� to su�p1Y data, buti refusal may req�ire that <br /> the C�.�y deny the pe�i� ar l�cense. <br /> 3. The in�ormati,on may b� shared with other :� �cal , e�� e� <br /> f e d e�a l �gencies to �he eXt�nt neregsaz� to process the p <br /> licens�. <br /> 4, �f your r�quested germit or �.ic�nse zec�uir�g Councii activn <br /> to approve, some ��format�Qn may become pub�.ic. <br /> �. You have certain righr� uncler M.S. 13.�4 to r��'-ew priva�e <br /> data on yourself. <br /> 6. YouX �u3.1 name is requ�.rec3 t�� �rocess �khis app�ication or <br />� perm�.t. _ <br /> �J��?A-�✓�- .9 I9-!r��5 �pv` S oc� <br /> F�rst Middle a�� <br /> i �'0 ,°G o C L�� � c� 5 <br /> PAddress <br />� �LC�oaL►�-�"� �� _ �11� ��� 2� <br /> City State �iP <br /> ���` �(P <br /> Phone <br />� Y understand my rights as stated above. <br />� <br />� <br />� Signature � <br />� sC wORKS—a�3•7359 <br />� BUILDING�tONiNC—473•7357 � AUMlNISTRATtON d2 FINANCE—477•7338 • pV�� <br /> �►SSESSiNC <br />