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� <br /> CITY of ORONO <br /> Poat Office Box 66•Crystal Bay,Minnesota 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 Iike 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 confidentia]. information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license reguested. <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 I.ocal, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. . <br /> 4. If your requested permit or license requires Counci3 action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review prica�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> C�.I�O�IrGI l�l�'1 <br /> First Middle Last <br /> 3 a-�� �6--��0�►� �. � <br /> Address <br /> VJ w-►z�`�- �'�'� �S3 � ( <br /> City State Zip <br /> � l� �`13 --�{3� <br /> Phone � <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDiNG&ZONING—473-7357 • ADMINISTRAT70N 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING - <br /> � <br /> 1 <br />