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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 PRIVACY ADVIS ORY <br /> In accordance with M.S. 13.04, Subd 2, "Rights of subjects of <br /> data", we would like to inform you that our 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 wi� 1 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 sharedl with other local, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or be lOene a regnresCouncil action <br /> to approve, some information may public. <br /> 5. You have certain rights under iM.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 /> First Middle i Last <br /> I <br /> Address <br /> City Zi State i P <br /> i <br /> i <br /> Phone <br /> I understand my rights as stated a ove. <br /> Signature � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINA!NCE—473-7358 • PUBLIC WORKS—473 7359 <br /> ASSESSING <br />