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.� � � ���1� <br /> ��'��' o O <br /> w s Post Office Box 66•Crystal Bay,Minnesota 5a323•Municipal Offices <br /> • <br /> � _ o , o 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 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 /> crualification 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 snared with other I.ocal , s�ate or <br /> f ederal agencies to the extent necessary to process the perntit or <br /> Iicense. <br /> g. If your requested permit or Iicense reauires Councii ac��or. <br /> to approve, some iniormation may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yoursel.f. <br /> 6. Your full name is required to proc�ss this application or <br /> pe*�it. <br /> First Middl.e Last <br /> Address <br /> City <br /> State Zip <br /> Phane <br /> I understand my rights as stated above. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 <br /> � PUBLIC WORKS—473-7359 <br /> ASSESSING <br />