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� � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � - o a On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 f rom 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 /> license. <br /> 4. If your requested permit or 3.icense requires Council action <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 process this applicatian or <br /> permit. <br /> �n'I /�-S �� . � �� L G <br /> � <br /> First Middle Last <br /> � I� � C,-� ,�c=d�-'D //� �( <br /> Address <br /> ��.� ��y�/�i�� � �S31/ <br /> City State Zip <br /> ���� �C '� � <br /> Phone <br /> I understa �my rights a stat�d above. <br /> �' <br /> - :,.: L � <br /> Sig ature <br /> Bl`1LD1NG& 7.ONING—473-7357 • AD�i1N1STRATION&FINANCE—473-7358 • PUI3IIC WORF:S —473-7359 <br /> ASSL;SSItiG <br />