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_ ���Y�j <br /> . ��� � CI'�Y of UROI�TO <br /> � - <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> I 9 <br /> ! On the North Shore of Lake Minnetonka <br /> � o - e o <br /> I DATA_PRIVACY ADVISORY <br /> � -- - - -- - - - - <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> ! would Iike to inform you that your request for a permit or Iicense <br /> from the City of Orono or any of its departments may require you to <br /> : furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to• determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become pubiic. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this application or permit. <br /> _� - : ; �� � � �u �`'� /�-� - -- <br /> � , _ -�------------_ - - <br /> _ - ---- -. ._._ <br /> _ .. ------ -... - -�-------_ ___.------- ----- <br /> First Middle Last <br /> � � ,_, , <br /> � <br /> , , . <br /> . , <br /> �C � I')J�.L%L�.�� J� � , ����-...... ,_._----- . _.. .. . .- --- <br /> Address <br /> , � �. <br /> . - � ----- --- -�c��c=- ._._..__�.��---�.-�---_ ----.�:,��_:t_.--'-----.- - -� - <br /> w�f' I 1 c: _ - <br /> City , State Zip <br /> �:'�._7�=�=�c�-C'-- --�-------------- . <br /> Phone <br /> I understand my rights as stated above. <br /> G' � � � �� <br /> `, �� ) j'(/'��� `� ' --._._'_G �C'�-----• --- •---------- • <br /> Signature , <br /> - _ _ . _ _ <br /> - BUILDiNG dc ZONING—473•7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLiC WORKS—473-7359 .`: <br /> A3SESSING <br />