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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 <br /> to inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may 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 <br /> the permit or license requested. <br /> 2, You may refuse to supply data, but refusal may require that the City deny <br /> the permit or ficense. <br /> 3. The information may be shared with other focal, state or federai agencies to <br /> the extent necessary to process the permit or license. � <br /> 4. If your requested permit or license requires Councii action to approve, <br /> some information may become public. <br /> 5. You have certain rights under M,S. 13.04 (see following page) to review <br /> private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �P i?�Q4�ir�� �l��rt'i �1 �„J�'t���a� / �IS=t'�e7�T � <br /> First Middle L� t <br /> ' �n �.�')� ;����� �t'�- /'�/ <br /> Address <br /> �i^�/5'�� �I�/ S�'� °z.-z� ��:� ��S����t�,,X-`� <br /> City � State Zip Phone <br /> I understand my righ s as stated above. <br /> � -� �y" <br /> Signature <br /> � F� (_. T��`�\ ^ � �` <br /> �s , ,, r � ,, , t. <br /> ,. �3� �, �, f;J i <br /> , S � . <br /> "�' � � _ ` — � a,; <br /> .;r �`4 � f t . 4.�� /���� <br /> � ' ..... �i��'�� _ ,.. i�:, � �'ry,c,a��� <br />