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� �o� <br /> � � � ��; <br /> ; 0 0��� <br /> ,, <br /> �� �-=� �.- '�`! CITY of ORONO <br /> ',�,� ����a;�t,�r-:� � .�� � <br /> � : � <br /> `�``�' ����' ��f ��� ti�;'' �o�soX�c <br /> �\�� Y�ti� �.x����, G,�, ���y,��ss�z3-oo� <br /> �kESII�g'�" , <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to <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 conf'idential information. <br /> You are notified that: <br /> 1. 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�t necessary to p:ocess the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become puolic. <br /> 5. You have certain ri�hts under M.S. 13.04 (see followin� paae) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRINT <br /> �tor�y l� I.�� �'�a-) <br /> First NSiddle I.ast <br /> I,PI�Y-� GoVt�'L?�-� f�lufJ�S � u.1G • <br /> '�l'� S�cnNO S'�P� <br /> Address <br /> ��,�,sioa. M� ��31 N�4-�I�-1 <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> '�nature <br /> TF'i.FPHO?VE-473-7357�FAX-473-0510 <br /> 1� <br /> ✓ <br />