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I�� <br /> CITY of OROliTO <br /> Post Office Box 66•Crystal Bay, Minneaota 55323•Municipal Offices <br /> • <br /> � - v � 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 3.ike to inform you that your request for a permit or <br /> I.icense 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 Iocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian or <br /> permit. <br /> � - <br /> < <br /> � <br /> First , Middle >L��� Las <br /> � ,-�� ' <br /> d ress <br /> �- `��'� .�l� `\ > � � � <br /> City State Zip <br /> �--( � `� = � �� Z � <br /> Phone <br /> I understand my rights as stated above. <br /> ���� <br /> , � <br /> Signat e • <br /> RUILDING&ZONING—473-7357 • ADbtIN[STRATION&F[NANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> � <br />