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I <br />DATA PRIVACY ADVISORY <br />In Acoonlance with M.S. 13.04, Subd. 2. "Rights of sut^ects of data", we would like to Inform you <br />that your request for a permit or license from the City of Orono or any of Its departments may <br />require you to frimish 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 />Noanse. <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 foil name is required to process this application or permit. <br />Middleia<r Last <br />i1 <br />Address <br />glK aioen <br />City <br />AiP ^33c^ <br />State Zip Phone <br />k I understand my rights as above. <br />;i> 'I <br />if . ■ <br />r.v <br />I- <br />► 1 <br />IrT- U . .• <br />a-'.V ■ rcsss?