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require you to fUmish 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 to supply data, but refusal may require that the City deny the permit or <br />license. <br />- ' <br />3. The information may be shared vdth 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.8.13.04 (see following page) to review private data on <br />yourself. <br />6. Your fuB name is required to process this application or permit. <br />______JAM-'i-c th^Ann._______ <br />Address <br />City <br />Pi\/gK <br />State Phone <br />I understand my righto as stated above. <br />Signature ^ <br />%. <br />JJ. <br />rp.y...•".v:O'>■ Iv*t» <br />fk <br />•^1 <br />’i ’ <br />V <br />ij'- <br />- <br />»,aI ‘3’‘^^e>o j <br />'nfsttomi I