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. � � <br /> � <br /> �_ . CITY of ORONO <br /> � Post Office Box 66•Crystal Bay, Minnesota 55323•MuniciPal 4ffices <br /> • <br /> � _ e � 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 like to inform you that your request for a permit or <br /> Iicense 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 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 , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Councii ac��o% <br /> to approve, some information may becnme public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6 . Your full name is required to process this application or <br /> permit. <br /> s��� <br /> ClG/�C� / Last <br /> First Middle <br /> ���� �U/�l� ���r� �P <br /> ^-L� <br /> Address <br /> i�!�D 1���� `�i'/r �-�� / <br /> City State Zip <br /> ��� - /��5� <br /> Phone <br /> I understand my rights as stated above. <br /> �� <br /> Signature <br /> BUILDING&ZOyING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />