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DATA PRIVACY ADVISORY <br /> In accordance 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 noti�ed 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 <br /> private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> RNo�►D� � 0�1.t� <br /> First Middle Last <br /> �,�j(c✓G <br /> �l�-14��W Ooig CZ.O�-D <br /> Address <br /> Oeotilo �w�Yt�i-�> NAnt 5 S3`t 1 to lZ- 8�0 - l0�3/ ' <br /> City State Zip Phone <br /> I understa m ights abo . <br /> ? <br /> Si a e <br /> � f�'v'c��'�'� <br /> � P��� <br /> ���� ��� �� � <br /> ���� y,�� �3�� <br /> Packet Last Updated: March 2014 <br /> Page 13 of 27 <br />