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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 /> qual.ification 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 /> licensee <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 to review privat� <br /> data on yourself. - <br /> 6o Your full name is required to process this application or <br /> permit. <br /> ,� , ,�`; <br /> �� g� �, ,; <br /> �� "� -.;�-f'�� ���'-(i�l l' '7 '�� <br /> � Middle Last <br /> First � <br /> �. � <br /> `;Z �_ � �,�, i;��,�� ��:���r.'1 �.' I�" <br /> Address <br /> � � <br /> ,� <br /> � �I ^/�, ',' " . ; ;�%� <br /> 4 � ' --, � ; �/�..�,i �� - I <br /> City State Zip <br /> ��i' - .-;. -� _ -;� <br /> < < `> <br /> Phone <br /> I ur�derstand ,r,�y rights as stated above. <br /> , <br /> , ! � ��_ <br /> �� />. i.� <br /> ignature <br /> BUILDING&ZONING—473-7357 • ADMINISTRAT[ON&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESS[NG <br />