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H <br />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 license. <br />3.The information may be shared with other local, state or federal agencies to <br />the extent necessary' to process the permit or license. <br />4.If your requested permit or license requires Council 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 />I .» <br />First Middle Last <br />Address <br />City <br />-g:ag-.s?- s <br />State Zip Phone <br />I understand my rights as stated above. <br />\ - ^ '’ii / <br />Signature 7-tt a' <br />rj