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.� <br /> . / , <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � � � � On the North Shore oj 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 /> 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 wil]. 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 local, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or I.icense requires Council. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data Qn yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �c�L�Pr� �< < < � � 1 �S l"91�1� <br /> First Middle Last <br /> ^ �� <br /> �I��� � yh�uc�d . _ <br /> Address <br /> I,rn�u�� �I�nv�- s�s��[�� <br /> City State Zlp <br /> � �T�� <br /> Phone <br /> I understand my rights �as stated above. <br /> Si nature <br /> BUILDING&ZOtY1NG-473-7357 • ADMINISTRATIOIV&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />