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JUN.25',2004 12:12 6127229754 GARLOCK FRENCH ROOFING #5245 P.003/006
<br /> Sec,13.04 RIGHTS OF SUBJECTS OF(IATA
<br /> Subs.I. Type of ditto. The rights of Individual on wise the dole is stored or to be stored shall be as set forth in this section.
<br /> Subd.2. Information required to be given lndlvitlud. An lndividtud tusked to supply prIent.c or confidential dela concerning himself shall he
<br /> informed of: fa)the purpose unit intended use of the requested ditto within the eollecthig state agency,political subdivision,or statewide system;(h)
<br /> whether he may refuse or Is legally regtired to supply the requested dntn;fc)tiny known consequence arising from Itis supplying or refusing to supply
<br /> prlvnl.eor confidential dote;and(d)the Identity of other persons or entitles euthnrired by state or federal law to receive the data_This requlrementahall
<br /> net apply when an iltdividunl Is asked to supply Investigative data,pursuant to section 13,61,subdivision 5,to a law enforcement officer.
<br /> 'nue rotitmiss1S11er of revet1lfer,tnay stone The entice rcnuj tp JjJis snhdlvtalnn In the.IndivldnnlllgiUc lout or nrottrrty tn>i.refund
<br /> instructions lnsteu i of on those.forms.
<br /> Siam.3. Assess to dole by Individual. Upon requital to a responsible a uthority.en Individual shah he informed whether he is the subject of
<br /> stored data on Indivitivals,and whether It Is classified ns public,private nr confidential, Upon lila further request,an Individual who is the subject of
<br /> stared private or public deco on lndividunls shall be shown the darn without tiny ammo to him end,if he desires,ahnll he informed of the content and
<br /> meaning of that dein, Allier on Individual hes been shown rhe prhvnle Ilnta and informed orb*meaning,the dole need not lie disclosed to him for els
<br /> months Ihcrenfhcr unless n dispute or nction pursuant In this section is pending or additional data on the Individual has been collected or eroded. The
<br /> responsible nntbnrfty shell provide copies of the private or public'hue upon request by theindivldunl sebjeet atilt;dote.The responsible npthorirymay
<br /> require the requesting person to pay the actual costs of molting,certlfying,,ied compiling the copies.
<br /> The responsible authority shall comply Immediately,If possible,with nuy request made pursuant to this subdivision,or within five days of die
<br /> date ofthe request.excluding Saturdays,Sunda.ya nod legal holidays,if Immediate compliance la not:possible,Ube cannot comply with the request within
<br /> tint time,he shall so Inform the Individual,and may have en additional five days within which to comply with the request,exrh,ding Sonrrdeys,Sundays
<br /> and legal holidays.
<br /> saw,4. Procedure when data it not accurate or complete, An Individual may contest the accuracy or completeness of male nr prfvaredate
<br /> concerning himself.To exercise this right,an Individual shall notify In writing the responsible anthority describing the nanireof thedisngreement_The
<br /> respnnalble authority shall.within 30 days either: fa)correct the date found to be hMaccnrate or Incomplete and attempt to notify post recipients of
<br /> Inaccurate or incomplete data.Including recipients named by the Individual:or(Ir)nntil, the individual HIM he believes the dein to he correct. Dote in
<br /> dispute shout be auscins:d only If the IndivldmUas statement of disagreement Is included with the disclosed dela.
<br /> 'Thr,delerminntion of the responsible aulhority may be nppenlcd porsunnt to the provisions of the administrative procedure eel relating to
<br /> contested cases,
<br /> DMA PRIVACY ADVf.SRY
<br /> O
<br /> in accordance with M.S. 13,04,Suhd.2,"Rights of sitbjtcts of data",we would like 1:o inform.you that your request
<br /> for a permit or license from the City of Orono or any of its departments may require you to furnish certain private or
<br /> 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 requested.
<br /> 2. You may refuse to supply data,but refusal may require that the City deny the permit or license.
<br /> 3. The informal:Ion may be shared with other local,stoic or federal agencies to the extent necessary to process
<br /> 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 favallable upon request)to review private data on yourself.
<br /> 6, Your fail name is required to process this application or permit,
<br /> 4i 4.r l 'Da V3 a fir`t 1,ii.)r
<br /> First Middle Last
<br /> 3 y5-*( Ave, 5-,Q
<br /> Address
<br /> M ,',... Ke.� � I 1 5 tr1Ai _ 5-s--90 E 6IP- ' '?6-940$
<br /> City State Zlp Phone
<br /> 1 und.erstand my rights as stated above.
<br /> • . 1 +
<br /> Signature
<br /> .!i i,..+', .';i'R sot Form
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