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� '� <br /> ���rY �� o�oNo <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> o. <br /> o _ � A On the North Shore of Lake Minnetonka <br /> DATA_PRIVACY ADVISORY <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 license <br /> f rom 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 license 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 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 public. <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 /> W 1�►'Ll1�o" � �I�� /%/ ------ --- - --- - <br /> First Middle Last <br /> S-9 7S Lv �_� � L v�---- -- - _.------ _ _ .. . ._ .._ <br /> -- - _. _ _ __ . _ _�._�r�-.._ _.�- - - --- -.----- ___. <br /> Address <br /> r'1'1�j�r�I� J�rti. S"s—���--- --�-----..._ <br /> ._. __ .. ---- _ <br /> City State Zlp <br /> y �� ^6��y . <br /> _ _ .- _ -- �-- <br /> Phone � <br /> I understand my rights as stated above. <br /> '� - - --- ---------- • <br /> Signature <br /> - BUILDiNG�ZONING—473•7357 • ADMINISTRATION&FINANCE—473-7358 . . � PUBLIC WORKS—473-7359 �`_� <br /> A3SESSING _ <br />