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In accorctance 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 firom the City of Orono or any of Its departments may <br />require you to fUmIsh certain private or confidential Information.1 <br />You are notified that <br />1. The information you fiimish will be used to determine your qualification for the permit or <br />license requested. <br />2. You may refiise to supply data, but refusal may require that the City deny the permit or <br />Noenae. <br />■•.V' <br />3. The infonnation may be shared virith 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 Coundi 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 fiiN name is required to process this application or permit. <br />First -r- ,4 Middle. Last <br />Address <br />Pix/Ct't)Al l2hi)‘iX\-NM <br />state Zip Phone <br />I understand my rights as stated above. <br />signature <br />•••> ..V <br />■ .Ia V <br />liaSwiiK' ■ • <br />J£ O fpi <br />4i <br />- \