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! <br /> L <br /> CITY of ORONO <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 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 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 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 ander M.S. 13.04 Lo review pri�ate <br /> data on yourself. <br /> 6. Your full name is required to process this apFlication o� <br /> permit. <br /> �Y U� �J ,�,�, ----r"�� 11 � <br /> tFirst Middle Last <br /> �� / ' �. ' <br /> / !L.�C-��� �.aJ CI z'k� t . <br /> Address <br /> � Cd N a ,�'�'l,'�,�,� �-���� `i 1 <br /> City State Zip <br /> �.� ;�'`.yd�% <br /> Phone <br /> I understand my rights as stated above. <br /> � � <br /> Signature <br /> BUILDING&ZOfYING-473-7357 • ADMINISTRATION&FINANCE -473-7358 • PUBLIC WORKS -473-7359 <br /> ASSPSSING <br />