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. + <br /> � <br /> C ITY of ORONO <br /> Post Office Box 66•Crystal Bay.Minneeota 55323•Muniapal OfFices <br /> • <br /> o _ � � On the North Shore of Lake Minnetonka <br /> D��� �R�YACY 1�V�SS2R� � <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 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 license requires Council 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 /> �.��_------- -- - e. . �"�C S--,-.-.-.... ---. .- -- . . ._�.�!.!_-----._.--- -�--- -- <br /> Fir t Middle Last <br /> a:3 .. ___ _ . . . <br /> �..._... _ .P__'_.-- -...._ ._.._. ...._. _..----- _ _. ... ._.--- <br /> Address <br /> �- -- - - ---._ .--.- -��._--- --.-- .------�s`"���___.--------- <br /> City State Zlp <br /> � ' <br /> ��.� -3�"� / -------__._------ <br /> Phone <br /> I understand my rights as stated above. <br /> Sign <br /> BULLDiNG&ZONING-473-7357 • ADMINiSTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />