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CITY f ORONO <br /> , Post Office Box 66•Crystal Bay,Minn ota 55323•Municipal Offices <br /> � - � On the North Shore of Lake Minnetonka � <br /> DATA PRIVACY ADVISORY <br /> Ini accordance with M.S. 13.04, Subd. 2, "Rights of' subjects of <br /> data", �ae would like to inform you that your request fo� a permit or <br /> licens� from the City of Orono or any of its department may require <br /> you to �urnish certain private or confidential informatian. <br /> Yot� are notif ied that: <br /> 1. The information you furnish wil.l 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 /> th� City deny the permit or license. <br /> 3. ' The information may be shared with other Ioc I, s�ate or <br /> fe�eral agencies to the extent necessary to process he permit or <br /> Ii ense. <br /> 4. If your requested permit or license requires Cc�uncil action <br /> to approve, some information may become public. <br /> 5. '� You have certain rights under M.S. 13.04 to re�iew private <br /> da�a on yourself. <br /> 6. Your full name is required to process this ap l.ication or <br /> permit. <br /> � ^ <br /> ^ <br /> Fi st Middle Last <br /> i I ( �S CT�Q . � � I � � <br /> Ad ress ' <br /> o�up . �36� <br /> Citly State Zip <br /> � (o�Z � �f� �---s� (s <br /> Phqne , <br /> I unde stand my right s stated above. <br /> C <br /> Si at e <br /> BUILDING&ZONING-473-7357 • ADMIlVISTRATION&FINANCE-473-7358 • P�BLIC WORKS-473-7359 <br /> ASSESSING <br />