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1 , . . <br /> _ � <br /> e <br /> ' � ` �� � CITY of ORONO <br /> x <br /> � , �. <br /> ,�t'�,, ,., }f, <br /> � � , .,- �';� . <br /> t� A,"���=,t' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> • <br /> � _ o ,�. 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 /> Iicense 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 wi3.1 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 Iicense. <br /> 3. The information may be shared with other iocal , 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 Councii action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to revzew pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this applicatian o� <br /> permit. <br /> �` � �lr-� :��' �: -� /.�S f� �<< � <br /> First Middle Last <br /> � f� �� � ���`��� '� �� r � �,�f '' <br /> Address <br /> ,l ,- - <br /> � . _ , <br /> , -�--, � . �� -.- � <br /> ����� �� t . _ �-�� � i., � 1 � <br /> City State Zip <br /> ' / / . • r~/ <br /> Phone <br /> I understand my rights as stated above. <br /> �'� _ , ,��;-� �. <br /> ;✓ , <br /> ,, , :� <br /> Signature <br /> BUILDING&ZOIVING—473-7357 • ADMINISTRATION&.FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING ' <br />