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� <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Officea <br /> • <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> 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 <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 Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�c <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> � � I � <br /> ` ` �r � � <br /> First Middle Last <br /> � �� 5�' (� �- o w � � � S � <br /> Ad ress <br /> � � z�� �,,,� n�� 5�S 3 � 1 <br /> Ci� State Zip <br /> h� 7 �. _ �I 7 �7 � <br /> Phone <br /> I understand my rights as stated above. <br /> � c � <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />