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A. <br /> CITY of ORONO <br /> CITY Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> OF <br /> ORONO On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> I <br /> In accordance wit M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like t 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 /> I <br /> You are notified that: <br /> 1. The informatid,n you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuseto supply data, but refusal may require that <br /> the City deny the pjermit or license. <br /> l <br /> 3. The informaticl <br /> n may be shared with other local, state or <br /> federal agencies tothe extent necessary to process the permit or <br /> license. <br /> 4. If your reques ed permit or license requires Council action <br /> to approve, some in ormation may become public. <br /> 5. You have certan rights under M.S. 13.04 to review private <br /> data on yourself. <br /> I <br /> 6. Your full namelis required to process this application or <br /> permit. <br /> `K a $AiL4 <br /> First Middle Last <br /> WS& cTA 419 <br /> Ad ress <br /> Onvut,6 I N 536 <br /> City State Zip <br /> 2.-0 --'l' ol (A w) lAi -S1ic 640 <br /> Phone <br /> I understand my rights as stated above. <br /> OUP— NA-114-114Signatur e <br /> BUILDING&ZONING—473-7357 • (ADMINISTRATION&FINANCE—473-7 35 8 • PUBLIC WORKS—473-7359 <br /> ASSESSING <br />