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' a <br /> CITY of ORONO <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> 0 1 On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data", we would like 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 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 <br /> h other local , tate or <br /> federal agencies to the extent necessaryto process the permit <br /> license. <br /> 4. If your requested permit or licensepublic.requires <br /> res Council action <br /> become <br /> to approve, some information may <br /> 7. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> Last <br /> First <br /> First Middle <br /> 17 3 Z 2-- <br /> Address Address <br /> LA Uk l <br /> City State Zip <br /> Phone <br /> I understand my rights as stated above. <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—373-7358 <br /> • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />