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�F. �►. <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> • <br /> � _ � � On the North Sh,ore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2 , "Rights of subjects of <br /> data", we woul.d 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 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 Iicense 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 iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or 3.icense requires Councii action <br /> to approve, some information may become publ.ic. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�� <br /> data on yourself. <br /> 6. Yaur full name is required to process this applicatian o� <br /> permit. <br /> � � � <br /> f�-� - `� ��-s� � �>�- � :,.._�r.,, s <br /> First Middle Last <br /> ;� � �� <br /> � - �GY�c�,,;, _ _ <br /> Address <br /> � .� <br /> /� a �.� /�'�,� �'�.� 'S".� 7 I <br /> City State Zip <br /> c� , � / � <br /> �l �� 5� � �� <br /> Phone <br /> I understand my rights as stated above. <br /> �.-----, <br /> �� <br /> -------- <br /> Sig �e <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FI�i aNCE-473-7358 • PUBLIC WORKS -473-7359 <br /> ASSESSING <br />