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DATA PRIVACY ADVISORY <br /> In accordanc�with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd: 2, "Tennessen warning", we <br /> would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br /> may require you to furnish certain private or confidential information. <br /> You are not�ed that: <br /> 1. The infonnation you furnish will be used to determine your qual�cation 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 /> cr (�e �vl,� � .� �S <br /> First Middle Last <br /> .3 � � Ci��f /?� � <br /> Address <br /> /,�!//�/lf�/!���Ci /j�� �S �,� � <br /> City State Zip Phone <br /> I und�rstand my rights as stated above. <br /> t <br /> ' re <br /> Packet Last Updated: April 2016 <br /> Page 9 <br />