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� <br /> CITY of O�iON� <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 /> 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 /> 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 license. <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 /> license. <br /> 4. If your requested permit or Iicense requires Councii actiar. <br /> to approve, some information may become public. <br /> S. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required �o process this application or <br /> permit. <br /> ��,1)�TC� � ���S l ����N� <br /> First Middle Last <br /> ���"J ���NV�C�OG7- � f��� � <br /> Address <br /> ������-- 'M� �53� 1 <br /> City State p <br /> �(n�� g-�� - ��1� <br /> Phone <br /> I understand my rights as stated above. <br /> � <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADM['.�ISTRATION&FINANCE —473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSIN G <br />