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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 <br /> that your request for a permit or license from the City of Orono or any of its departments may <br /> require you to furnish 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 permik or <br /> license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information <br /> may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> P�����- u� i v�� ,��- C�G��.��-c�..� <br /> Firs�� ��� j� Middle La 't <br /> , <br /> Addre�s � <br /> —�L�LS��'� y�l�' ��3s� ��lZ �z� �5��- <br /> City State Zip Phone <br /> I understand my rights as s ted above. <br /> � U��� C)W <br /> Signature <br /> ,., <br /> _--.. ,_ _ <br /> r � .. s �1 � ._�.I� - ` . <br /> , .- ... <br /> .. �'�! ,��� <br /> . ... . � ._, .... .�i _.. <br />