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� <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minneaota 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 l.ike 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 confidentia3 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, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Council act�on <br /> to approve, some information may become pub3ic. <br /> 5. You have certain rights under M.S. 13.04 to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> � l�l p� P ���{�n�c�G- <br /> First iddle Last <br /> �o ��J ci'� �O <br /> A dress <br /> ,/.L�� %� �Z/"� .��� ��S� <br /> City State Zlp <br /> �o�S -`�`��� <br /> Phone <br /> I understand my rights as stated above. <br /> .� <br /> r <br /> Si na ure <br /> BUILDING 8c ZONING—473-7357 • ADMINISTRATION�FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />