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�/ � ' � <br /> /� <br /> � � <br /> O O <br /> � C ITY of ORONO <br /> ,� ' '� �. _ �+ Mu„x;�►or� <br /> ��, <br /> � ti Posc of6ce BoX 66 <br /> �� '-� '�+� : �,' =`r G~' Crystal Bay.Hinmsot9 55323-0066 <br /> � .;!. .,_ � <br /> 9kESI30g' <br /> \ �. <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 Ciry 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 /> rermit or license. <br /> 3. The information may be shared with other local, state or federal aaencies to the <br /> extent 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 public. <br /> 5. You have certain ri�hts under M.S. 13.04 (see following paQe) to review priva�e <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRLNT <br /> �,� o �. _SG£ <br /> First � Middle Last <br /> ��'� � — �3 ? �`' a�- /tr� �� <br /> Address <br /> � . � a� ��-� '���� <br /> Ciry State Zip Phone <br /> I understand my rights as stated above. <br /> igna re <br /> � �PxorrE-ar�-�•Fax-a�osio <br /> 10 <br />