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� <br /> � <br /> ��'��' �� ���1�'� <br /> a Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> A <br /> '_ o � � .�s�. <br /> On the North Shore of Lake Minnetonka <br /> DATA_PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or �icense <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> l. 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 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 Counci3 action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6, Your full name, and date of birth are required to process <br /> this application or permit. <br /> � �-��_-- _._ �a��-.- ---- -_��.`''`-.��'L,------------ .--. <br /> 4� Middle Last <br /> First <br /> . f� <br /> - <br /> ���Q � � �--- . ..1./_�-----�-��----. .. ... _.------ ._. ... . -- <br /> Address � / , <br /> �GIOD�i��_ _.�".,a.._�.C�C._._/�'�,'�i��__.__�`-�-�--`�� ._.-----��-- <br /> .-�----- <br /> City State Zlp <br /> ��� �� �� � - --- --- -- <br /> Phone <br /> I understand my rights as stated above. <br /> d <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMIIVISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br /> 5 <br />