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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 notified that: <br /> .. ";nE inrc��mation you furnish will be used to determine your qualification for the permit or license <br /> ,��q u�stEd. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. Tne ;nformation may be shared with other local, state or federal agencies to the extent necessary <br /> tc Nrocess tne permit or license. <br /> 4. !r your requested permit or license requires Council action to approve, some information may <br /> becomz public. <br /> ;,. Y�„ ;�a��certain rights under Minnesota State Statute 13.04(see following page)to review private <br /> ua_� �r, yourself. <br /> c- Yeu�;u11 name is required to process this application or permit. <br /> .�.�./� C�s-���,��,� ��u <br /> ��; ` /�.,,�.,.- /���..1�-► <br /> F�rst �-t-� �1�_����Middle Last <br /> 1�u� �7� �9�-�- �. <br /> Aadress <br /> 5��� ,�N �� 3?`� <br /> City State Zip Phone <br /> � ,anuers.u�:�, my �ights as stated above. <br /> J;t�rlai�.11C � 1) ��,'�r� <br /> RECEIVED <br /> Packet Last Updated: August 2015 <br /> OCT 26e�w� <br /> Page 7 <br /> C1TY OF ORONO <br />