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i <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04. Subd. 2. "Rights of sut^s of data", we would like to inform you <br />that your request for a permit or license from the CKy of Orono or any of Its departments may <br />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 />Hoense requested. <br />2. You may refuse to 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 />f\AiCLftiCoJ <br />Address <br />_____________________________ <br />Middle Last <br />City State Phone <br />I un^rstaad my rights as ^aM above <br />lignature f <br />on, I <br />V-. i.-'S V HI<: .*9 P-5S2 <br />I <br />.A