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� <br /> ' ' 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 fo�r a permit or license from the City of Orono or any of its departments <br /> may require you to fumish certain private or�onfidential information. <br /> You are notified 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 shated with other local, state or federal agencies to the extent necessary <br /> to process the permit or licerlse. <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 unde�Minnesota State Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to brocess this application or permit. <br /> r�_ <br /> First Middle Las <br /> ��U // �` �ic S�. <br /> Address <br /> � <br /> City Sta I Zip Phone <br /> I und st d my rights a ta abovg. <br /> Signature <br /> � <br /> CUP Application-January 2017 <br /> Page 14 <br /> I <br />