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.. ,:,,� _ <br /> - _ —_---� —__ , __ <br /> .__ _.. __. �.. �. ._.e��. _.. ___,_....._....__:_.�„ <br /> � ���, <br /> O �..,- O\ <br /> ;��;::��.-, � 1 CITY of ORONO <br /> � . , �� �;!� <br /> ,,�'� "j�..c' --. Municipel O[Hces <br /> ',', !� e�':,'S�:�.'.'1� ,�,�'/ Post O�ce Box 66 <br /> '��'�'�'4L j.,l;�,���. G crysw say,��ss3z�oor� <br /> ,,,,� .g,'�j/' <br /> �k'ES�ID <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data , we would like to <br /> �� <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> 2. 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 other local, state or federal agencies to the <br /> exter�i necessary t� p:ocess �h� permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> 5. I�ou have cer�ain rijhts under M.S. 13.04 (see followin� paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> Jc�m� /YO/'man J�h��h <br /> First Middle Last <br /> Go / <br /> Address <br /> �'�'� /1�n -�`305 �1-5 -oSy� <br /> Ciry State Zip Phone <br /> I understand my rights as staced above. <br /> ignature <br /> TELEPHOfYE—473-7357�FAX-4'73-0510 <br />