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. <br /> � <br /> CITY of ORONO <br /> Post Office Box 66•Crystai Bay,Minnesota 55323•Municipal Offices <br /> � <br /> � - � � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY AD�7ISORY <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 /> 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 wiZl 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 Iicense. <br /> 3. The information may be shared with other iocal , state or <br /> federaZ 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 public. <br /> 5. You have certain rights under M.S. 13.04 �o review pri�a�e <br /> data on yourself. <br /> 6. Your full name is required to process this apglicatian or <br /> permit. <br /> . . , <br /> r , <br /> � ��-L'��`�j ��f<�f k�:'< < < ��L iG c i,�v <br /> First Middle Last <br /> , , <br /> -��� �, r �;� �� �... �����j <br /> Address <br /> / j �J� `/ <br /> ,���c (f��t,ir��,_�,� <br /> i+;�.; <br /> City State Zip <br /> �`,/j�?' ✓S :I 1 <br /> Phone <br /> I understand my rights as stated above. <br /> � , � > �_\ <br /> ��� /` <�-. <br /> Signature <br /> BUILDING&ZOIYING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBL[C WORKS-473-7359 <br /> ASSESSING - <br />