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.`''� � <br /> /�g o'� <br /> ,o o � <br /> �,� � DATA PRIVACY ADVISORY <br /> �l �G <br /> .,����} <br /> In accordance with M.S. 13.04,Subd.2, "Rights of subje�ts of data",we would like to inform you that your <br /> request for a pennit or license from the City of Orono or any of its departments may require you to fumish <br /> certain private or confide�ial inf�mation. <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 shazed with other local,state or federal agencies to the extent necessary to process <br /> the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may become <br /> public. <br /> 5. You have certain rights under M.S. 13.04 to review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> rra�:_�'��'�'�/Tir�/ �J� �(/�"�ir� <br /> first middle last <br /> ADDRESS: ��� �o/!��S '�GG�i� <br /> hoase namber str�eet <br /> 1�k/ �l.A�i�. G�/� �f�D l <br /> city state ,�p <br /> DATE OF BIRTH: � �_�Lf�PHONE: 7�03"'�y�-�'��o�fo <br /> month/ day / year <br /> I nnderstand my ' ts as stated above. <br /> 2,// <br /> �a�� aate <br />