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DATA PRIVACY ADVISORY <br />In accordance 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 from the City Orono or any of Hs departments may <br />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 the permit or <br />license requested. <br />2. You n>ay 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 bacome public. <br />S. You have certain rights under M.S. 13.04 (see foltowing page) to review private data on <br />yourself. <br />6. Your foil name is required to process this application or permit. <br />fAadW______TWiK>l_____ <br />First <br />Add <br />Last <br />rm <br />City State <br />SS3M ist-Hnosn <br />Zip Phone <br />I understand my rights^stated above.U^UL2I^___ <br />Signature <br />V‘4.. <