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� <br /> CITY Of O��liT� <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. 15.165, "Rights of subjects of data", we <br /> would Iike to inform you that your request for a permit or Iicense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidentia'3 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 license. <br /> 3. The information may be shared with other IocaZ , state or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or license requires Council action <br /> tc� apprcve, same inf�rmation may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> � data on yourseZf. <br /> 6. Your full name, and date of birth are required to process <br /> , this application or permit. <br /> __ . . _ _- . <br /> . _ _.. _--------- ---�- -.-.._...- -- - ---�--- - <br /> �--- - ---� <br /> _ <br /> First Middle Last <br /> Address <br /> _ .____ ._ .._ _ . - -- - -- -� -- --.. . __.._- �--�---- -�----- <br /> _ . - <br /> City State Zip <br /> __ __... . <br /> Phone <br /> I understand my rights as stated above. <br /> �; <br /> ,-�' <br /> � . <br /> , , - --. .-------__ _--� ---__-.__ - <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />