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. � , <br /> �� � <br /> C ITY of ORONO <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 3ike 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 confidentiaZ 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 supp3y 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 grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this apglicatica or <br /> permit. <br /> �,'� �`�� � � c.ti��� r' _ <br /> First Middle Last <br /> �=�� y � . � � <br /> � ��_� �� �� �� �� -� n� e �--� '� -- <br /> Address <br /> �' SSsS � <br /> �=� �� �= ,_ � ���t ,�� _ <br /> City State Zip <br /> �,,� 7�� �r2 ��i r� y 7�� 7��13 - <br /> Phone <br /> I understand my right_s, as stated above. <br /> �� <br /> ' � /%� �_,✓" <br /> � � <br /> ��� <br /> Signature <br /> � <br /> BUILDING&ZONING— 473-7357 • ADMINISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />