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DATA PRIVA Y ADVISORY <br /> In accordance ith Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br /> would like to i orm you that your request for a permit or license from the City of Orono or any of its departments <br /> may require yo to furnish certain private or confidential information. <br /> You ar� notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or license <br /> requested. <br /> 2. , You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. ' The information may be shared with other local, state or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may <br /> become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �C'�c�'_ ��\?�`r�:� \1���� <br /> First Middle Last <br /> �.\`1 � ���c� ���� <br /> Address <br /> V�O� �� �uJ � �`�� - I ���� / <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> e <br /> I <br /> ', <br /> �I <br /> i <br /> Packet Last Update�• August 2015 <br /> Page 7 <br />