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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 Iike 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 /> 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 Iicense. <br /> 3. The information may be shared with other iocal , s�ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii ac�ior. <br /> to approve, some information may become pub3ic. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ��'h � t I �� V�1�����,�� �++� <br /> First Middl.e Last <br /> (�U`-� G -_�.�-1-r��v,r�� �c�� � � 2�i <br /> Address <br /> �� 1 �`l Vl C-�vv{�E� <<�Y �/"' �����/=� <br /> City State Zip <br /> C�+ Z) `-I �'�= --���s <br /> Phone <br /> I underst� my rights as stated above. <br /> % <br /> i � - <br /> /�f, <br /> � <br /> Signature <br /> BUILDING&ZOIYING—473-7357 • ADMINISTRATIO[V&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />