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, <br /> � <br /> ry�;;�, <br /> x �+i <br /> � `G �, <br /> CITY of ORONO <br /> Post Office Box 6&•Crystal Bay,Minneaota 55323•Municipal Officea <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 3ike 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 /> 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 supp3y 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 m�y become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> E. Your full name is required to process this applicatian or <br /> permit. <br /> � ic�k. S NI � 1 ,' � � (<�,���y�; Sf�►�� <br /> First Middle Last M�(I P�' <br /> �j� � '-� ��,���� t r� A't1`�, <br /> Address <br /> �` � � �l S S ��� �. <br /> City State Zip <br /> ���� � �'���� <br /> Phone <br /> I understand my rights as stated above. <br /> Kw�� � — <br /> "-:,,,��:,-� �� 1,�-�,Q�� <br /> Signatur� � <br /> BUILDI[VG&ZONIIYG-473-7357 • ADMINISTRATIOfV&FINANCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSI\G <br />