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• <br /> ?F�7 <br /> _�. � ^ - . NO <br /> �ITY og ORO <br /> Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> •. _ <br /> � _ � A 4� 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 license <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 /> 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 /> �icense. <br /> 4. If your requested permit or license requires Counci 1 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 /> . 2.��6�i_ -. ---.-�1����.-�---- . ___. . 2�--- --. ------. <br /> First Middle Last <br /> �C�O N- �� 2� - - - - - <br /> Address <br /> ------ . . �D�b--- .- --- - ....._._.- --.-��-.._----------�--:---S _ �------��-- <br /> City State Zlp <br /> �7����� C - --.-.---.--- � ----- . <br /> Phone <br /> I understand my rights as stated above. <br /> Signa ure <br /> BUILIIING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSIIG <br />