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, . <br /> � O� � <br /> ,O O `��\ <br /> � j�.' 1� <br /> ; -=:f,,,_`-, T �,; CITY of ORON4 <br /> 1l � �F�a�.' )��j ^Y �;� �P��10E�� . <br /> � <br /> ''� 1� � ��l`; c4 � <br /> �,;����;;,.`���. Oti� cry��y,:�s�o�s�Z3-oo� <br /> �L � :�v:�''._���`��'/i <br /> �kESI-�� <br /> DATA PRIVACY ADVLSORY <br /> In accordance �vith M.S. 13.04, Subd. 2, "Riahts of subjects of data", ��e would lil:e to <br /> inform you that your request for a permit or license from the City of Orono or any of ics <br /> deparunents may require you to furnish certain private or co�dential information. <br /> You are notified that: <br /> 1, The information you iurr.ish w ill b� ��sed to determine your qualification for the <br /> permit or license requested. <br /> ?. You may refuse to supply data, but refusal may require that the City deny the <br /> permit or license. <br /> 3. The information may be shared with oLher local, state or federal aQencies to the <br /> extent necessary to process the permit or licer.se. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> j. You have certain rights under M.S. 13.04 (se� followin� paQe) to review private <br /> data on yourself. <br /> 6, Your full name is required to process this application or permit. <br /> PLEASE PRL'�'T <br /> � � ���,; �p �� j�--�(.��� <br /> � ��� , � � <br /> First Midd e Last <br /> ��� � . �, : '-�- �- �""` " <br /> . � �� � , ti -�� <br /> Address � <br /> �� � y�/�"���� <br /> '�f�l �r�.�� � ��;-� c�� � n� S � <br /> Citv State Zip Phone <br /> I understand my riahts as stated above. <br /> L-`�,t�y���� �. C.�� ��.F , <br /> SiQnature <br /> v TELEPHO�'E-473-73�• F.�►.Y--t73-0510 <br /> 1� <br />