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;:� ---- <br /> � . - —- — ----- _ <br /> DATA PRIVACY ADVISORY <br /> In accordance with Minnesota�State Statute 13.04 Rights of 5ubjects of Data, Subd. 2, "Tennessen <br /> warning", we would like to inform you that your request for a permit or license from the City of Orono or <br /> any of its departments may 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 or . <br /> 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 Minnesota State Statute 13.04 (see following page) to <br /> review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> ST��.�EW 1� s c.Nw;�T t� � s <br /> First Middle Last <br /> � � / ��}- ��.r V� �� � � i <br /> Ad-'d sE--�;° <br /> M� �f V ir'��- 1 O w �� �� s, 3 7 � • 9.S � 3 7 S �Q�7 V� <br /> City State Zip Phone <br /> I understand my rights as ove. <br /> _--- - _ ; <br /> Signature <br /> Packet Lasf Updated.� 04/19/2093 <br /> Page 20 of 23 <br />