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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 <br /> your request for a permit or license from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidentiai 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 /> 3. The information may be shared with other locai, state or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may <br /> become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> ����{'�S -����'� N�'����, ���'S�� <br /> FIRST MIDDLE LAST <br /> I/C� -=�-�+.�r, 1����' (�� <br /> ADDRESS <br /> CITY M.c�,n��a ,�� �� STATE, ZIP /�r��.� �jS��CJ PHONE �l� � • ,��'c,4 <br /> I understand y r' ts a state above. <br /> ���- G t� -�-�-�--'�-- <br /> Signat e <br /> f'�+ �7 ' 1� ( �' 1.�. <br /> �•'^� � ,. ( � ..\ <br /> i ... ' , . - 'I�, �� <br /> N _., - � . .. __;;/._j; <br /> � �� �_� � .. , �. J./:: <br /> ��w.,:,_� <br /> _ 1`t _ <br />