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' � �.�r,���av.�cx,��vflso�� � <br /> In accordance with Minnesota S#afe Statufe 13.�4 Rights of Subjec#s of Data, Subd. 2, "Tennessen warning",we <br /> would like ta inform you that your requesfi for a permit or]icense from fhe City of Orono or any of its departments <br /> may require you to furnish certain privafe or confidenfial infarmation. <br /> You are notified fhat: � <br /> 9. The information you furnish will be used to determine your qualification for fhe permit or license <br /> requested. � <br /> � 2. Y�v may refuse fo supply dafa, 6ut refusal may require tha#fihe City deny the perrnif or license. <br /> 3. � Tf�e informafion may be shared with afher(ocal,sfate or federaf agencies to the exfent necessary <br /> to process fhe permif or license. ' <br /> 4. If your requested permit or license requires Council action fio approve, some informatioh may <br /> become public. <br /> �. You have certain rights under Minnesota State Stafute 13.04�(see following page) to revie�,v <br /> private data on yourselfi. <br /> 6. Your full name is required to process fhis applicafion or permifi. <br /> Y�►Ei�1+�' �� �cl�dQ-J'� <br /> First Middle . �asf <br /> toli'7 Bw�� C,r�u,,� �R-�vE � <br /> Address <br /> _ 1M f N N�r��r�t �N 55343 45z � 34�-as¢3 <br /> Cify State Zip Phane ' <br /> I understand my rights as stafed above. <br /> Signature . <br /> PacketLast Updated• January 2�75 <br /> Page 7 <br />