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�. <br /> CITY 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 like to inform you that your request for a permit or <br /> Iicense 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 wi3Z 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 license. <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 /> Iicense. <br /> 4. If your requested permit or Iicense requires Council actior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � ,= <br /> � , �,�u�- l� `� C �1 �- � - <br /> First Middle Last <br /> ��� � n ��� � � � � � ����� � ��� <br /> Address �/ <br /> 1`"�, �� �� � S G f�� � ' <br /> City � State Zip <br /> - -� � � ��, � �T <br /> Phone <br /> I understand my rights as stated above. <br /> _ _ _� _ <br /> .. <br /> ___� <br /> ,=,'" <br /> Signature <br /> � <br /> i <br /> i <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-73 8 • PUBLIC WORKS—473-7359 j <br /> ASSESSING i <br /> � <br />