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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 departrnents 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 permit or <br /> license requested. <br /> 2. You may refuse fo 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 /> Tr��� ���� �f� J� � � ��� <br /> First � � Middle Last <br /> �7��� ��y ���T l� �-�-, <br /> Address <br /> �k �1�� �( � �� ��a �tf� ��> ��o (�1�� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> �Z� �/����-� <br /> Signature � <br /> �� 1 (!•`'-�-' �) f- <br /> J <br /> � �Y t �, <br /> ,� . .. ... ... / . . . <br /> �-.: . � <br /> i: .�-_l'.) . ".. , ..:'. <br /> � 1 .. .. ... .. � <br /> f �� `,'�� _ I <br /> .. ... _.. _..�1 <br />