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.,�.,., ~ ..,,,,. <br /> � <br /> ..��� �' r� <br /> � �i��� O� ����� <br /> �yg��:.. � ��`:: <br /> �� �. <br /> ._..;.r,�^-4 v-:�`�u <br /> a ��t.'�-'�h Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> _-�.�.�� <br /> ! <br /> � _ � � 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 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 wi3.1 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 /> Iicense. <br /> 4. If your requested permit or Iicense requires Counci.i. ac�io% <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 application or <br /> permit. <br /> �,; �(` �, % ( � ,`. -� ,-- <br /> � � A�1�! /t, ` � � l '� i. -'�(°; <br /> First `, Middle Last <br /> � ��C��� � ► � �'C ��� �,�� � ��-� ������ - <br /> Address <br /> r <br /> ���\ � � t=-� 'c �l <br /> (� ' I ��� ( �- ' <br /> City State Zip <br /> r����� � � L, �=�� <br /> ; . <br /> Phone <br /> I understand my rights as stated above. <br /> � � � _ �,, <br /> � � � -�_�l � �� <br /> Signature . <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />