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r� �� <br /> � <br /> C I�`Y of OI��NO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ! <br /> � � � � On the North Shore of Lake Minnetonka <br /> DATA PRNACY 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 f rom 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 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 local , s�ate or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii act�on <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 proc�ss this appl.ication or <br /> permit. <br /> ,.� f - ,9^/'rL��!/ <br /> �� 5 Last <br /> First Middle <br /> � �� <br /> � 7 — <br /> ddress <br /> � o-� �Z � ��� <br /> Cit State Zip <br /> ��c�� . `�/Z� <br /> Phone <br /> I understand my rights as stated above. <br /> � gnature • <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />