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��r�,��ivAcv��v[sor�v <br /> In accordance with Minnesota S#afe Statute 13.04 Rights of Subjecfs of Data, Subd. 2, "Tennessen warning", we <br /> wouid like to inform you that your request for a permit or license from the City of Orono or any of its deparfinents <br /> may require you to furnish certain privafe or confidenfial information. <br /> You are notified thaf: <br /> 1. The information you furnish will be used fo determine your qualification for fhe permit or license <br /> requested. <br /> � 2. You may refuse to supply data, but refusal may require tha#tne City deny fhe permit or license. <br /> 3. The informafion may be shared with other local, state or federal agencies to the extent necessary <br /> to process fhe permit or license. <br /> 4. If your requested permit or license requires Council acfion to approve, some information may <br /> become pu6lic. <br /> 5. You have certain rights under Minnesota State Sta#ute '13.04 (see following page) to review <br /> private data on yourself. <br /> 6. Your fiull name is required to process this application or permit. <br /> �Yl�n- .�.a�� J�,r�ro <br /> First Middle Last <br /> �O I 1"1 B l�� C.�t.� D W v� . <br /> Address <br /> _ i�V,t N N�t�,,.t W4 6N�N 5 5 34 3 4 5 2 - 34 5-b5¢3 <br /> Cify State Zip Phone <br /> I understand my rights as stafed above. <br /> Signature <br /> PacketLast Updated.� January 2095 <br /> Page 7 <br />