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- - _ _ <br /> . ' <br /> �.�;'A PRIVACY ADVISORY <br /> -����raance witn iviinnesota State Statute 13.04 Riphts of Subiects of Data. Subd. 2. "Tennessen warnina". we <br /> =uia nKe to inrorm vou tnat vour reauesi Tor a permit or iicense from the Citv of Orono or anv of its deqartments <br /> mav reauire vou to furnish certain qrivate or confidential inTorma*�c� <br /> You are notified th�� <br /> ' r'�e information vou furnish wilt be used to determine vour aualification for the qermit or license <br /> requestea. <br /> 2. You may refuse to supply data, but refusal may require that the City aen_y tne oermit or iicens� <br /> 3. The information may be shared with other local, state or federal agencies t�the excent 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 nubiic <br /> 5. You have certain rights under Minnesota State Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this appiication or permit. <br /> �-c,(�z�t�e�l� ��h�/�� �-�-�,���� <br /> First Middie Last " <br /> �=?�v �,������ ��.�;E'i �':;���".� <br /> r,ciciress <br /> ��'c��'"s s:� ";;��y '' ,. � <br /> � � `��' ( • 7$l� ��11 <br /> Citv State Zip Pnor.: <br /> f understand mv rights as stated above. <br /> � � � � <br /> Sianature <br /> RECEIVED <br /> �o�nC�Ld,�tJ�JOaL6O: .'1U9USi LU75 _ _ ��� � p 2016 <br /> �tTY OF ORONO , <br />