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� r�.��r���av�,cx���asor�v � <br /> fn accordance wifh Minnesota�S#afe Stafufe 13.04 Rights of Subjecfs of Data, Subd. 2, "Tennessen warning",we <br /> would like to inform you that your requesfi for a permif or license from fhe Cify of Orono or any ofi its deparfinents <br /> may require you#o furnish certain privafe or confidential informafion. <br /> You are notified fhat: � <br /> 1. The information you furnish will be used fo defiermine your qualification for the permit or license <br /> requested. <br /> � 2. Yota may refuse to supply data, 6ut rafusal may require that#he City deny the permif or license. <br /> 3. � The informafion may be shared with ofher focal,sfate or federaf agencies to the exfent necessary <br /> to pracess fhe permif ar license. ' <br /> 4. !f yovr requested permit or license requires Council acfion fio approve, some informatioh may <br /> become public. <br /> �. You have certain rights under Minnesota State Stafufe 13.04�(see following page) to reviei,v <br /> privafe dafa on yourselfi. <br /> 6. Yourfull name is required to process this application or permit. <br /> �1'P" �� �u��-J�� <br /> First Midd(e . � Lasf <br /> �O I l� 6 w�� G'�P.u,.�. D W v E � <br /> Address <br /> iM}N��r�rwt aMN 55343 452 � 345-as¢.3 <br /> City S'tate Zip Phone � <br /> I undersfand my rights as stafed above. <br /> Signature . <br /> PacketLast Updated• January 2095 <br /> Page 7 <br />