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'. , � <br /> � w�: <br /> = �I'T�' O� OROIlTO <br /> � <br /> Post Office Box 66�Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> s _ � v On the North Shore of Lake Minnetonka <br /> DATA PRNACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of sub erm t or <br /> data", we would like to inform you that your request for a p <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 /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to suppl.y data, but refusa3 may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local. , s�a�e or <br /> f ederal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council act�or_ <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6 . Your full name is required to proc�ss this application or <br /> permit. <br /> 1_ , 1 � � l; ,� i �C �`, , <br /> c... � <br /> `___.. .,l ; /t c Las� <br /> First Middle <br /> , <br /> � > � <� _ � � � �."��-,� � �/ �c <br /> �,- i <br /> Address � . <br /> , � � �� '°� j ?� �/ <br /> �, _ � <br /> . "j �i� C C���� � c , i- � - <br /> City State Zip <br /> �� �/ <br /> , - <br /> / ,� ;. ( <br /> `�'�-�� � <br /> Phone <br /> I understand my rights as stated above. f`/ <br /> / / `,s ; <br /> ' ° J , � _�l / C�-�lG �r,�, <br /> �, �'�/ C � �---� /��' ( �� <br /> , <br /> Signature ' <br /> BUILDING&ZONING—473-7357 <br /> • ADMINISTRATION&FINANCE—�373-7358 • PUBLIC H'ORKS—473-7359 <br /> ASSESSIN G <br />