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� <br /> i;z <br /> "se. <br /> ����� ¢�� C ITY of ORONO <br /> �� <br /> .�:,�:���.: <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <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 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 /> 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 /> federa.I agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. actian <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian or <br /> permit. <br /> f � s',., ''\ <br /> 1 �N s, , ; 4,.- yJ f""� , `--''- ,�- /i °}""�,,� ,�'r <br /> irst Midd e Last <br /> ���� �� e��� ""..✓�� ,�� � <br /> Address <br /> +°I ��� �° ' �, ,;'.ti i�:. � / �✓ �;� S�'..���� ! <br /> City State Zip <br /> �,�„,�-� 'f' �'"�* ��t �""". <br /> � ' <br /> Phone <br /> I understand my rights as stated above. <br /> , � <br /> � � <br /> , � <br /> , <br /> , -.�`:., ,,, e...Y r- ' ,��,+ . aR""�. �,.�.�. <br /> S gnature � <br /> BUILDING&ZON[NG-473-7357 • ADMINISTRATION&FINAVCE -473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />