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k ' • <br /> � O � <br /> O o <br /> C I Y of ORONO <br /> �, ` ' ^:. �, �t,u,k��ot� <br /> c4 r�c om�s�X� <br /> �'C� . ,F : �J~ CrysYal Bay,�finnesota 55323-0066 <br /> ��kESH��� <br /> DATA PRIVACY VISORY <br /> In accordance «�ith `1.S. 13.0=�, Subd. 2, "Ri hts of subjects or data", we would like to <br /> inform ��ou that ��our request for a permit or licen e from the Cirv of Orono or any of its <br /> departments mav require you to furnish certain priv te or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be u ed to determine your qualification for the <br /> permit or license requested. <br /> 2. Y'ou may refuse to suppl�� data, but r fusal may require that the City deny the <br /> Ye:�nit or license. <br /> 3. The information may be shared ���ith ther local, state or federal aQencies to the <br /> exten� necessary to pr�cess tr�� perrnit or license. <br /> 4. If ��our requested permit or license r quires Council action to approve, some <br /> iniormation may become puolic. <br /> �. You ha��e cer�ain ri�hts under M.S. 1�.04 (see fo?lo«�ina paae) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLE�SE PRL'�TT <br /> �� ��q� ,�.��r/��'O�.' <br /> First i�lidd:e Last <br /> �(4 �D (j,a� ,S(D /��� <br /> Address <br /> ��J,,7 �t�1/l� 5 S3 S� �f Y f -o� 1.� <br /> Citv State Zip Phone <br /> I understand my riahts as stated above. <br /> `�/��/LG'`— ' "-t�- <br /> SiQnature <br /> ` TELEPHONE-473-7357• t--t73-0`10 <br /> 10 <br />