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� <br /> � 'v 1 i f ��,;,� <br /> e>�-r�ati� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform <br /> you that your request for a permit or license from the City of Orono or any of its departments may <br /> require 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 qualification for the permit <br /> or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information <br /> may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �" ��\�U��\v� ��r� �� I I � �' <br /> . , <br /> j �%� , <br /> First J Middle Last <br /> _� <br /> ��� - �) ��; �>r �1 ��.��r�'� <br /> Address <br /> ,- � ,- ,-;• .- -- ._ <br /> �_�'1��''t'��7' �'�� i�1 �5.� f% �/ /� �? `/�� ..i <br /> City State Zip Phone <br /> I, 'der�and my 'g�s as stated above. <br /> � �'� , <br /> � � � � <br /> �,�i''gnature� <br /> i <br /> 9 <br />