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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you that your <br />request for a permit or license from the City of Orono or any of its departments may require you to furnish <br />certain private or confidential information. <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 />The information may be shared with other local, state or federal agencies to the extent necessary to <br />process 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 />Per Chapter 30 of the Orono Minnesota City Code, a computerized criminal history inquiry and/or a <br />driver's license history inquiry on the applicant may be conducted to verify the information provided <br />with the application. <br />NAME: &Y ' FLJA " <br />ADDRESS: <br />first <br />house number <br />middle <br />last <br />�4✓R�/N� c�4-LS <br />street <br />city state zip <br />DATE OF BIRTH: PHONE: <br />mon hl day 1 year <br />I understand my rights as stated above. <br />date <br />Page 5 <br />