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DATA PRIVACY ADVISORY <br />In accordinoe with M.8.13.04, Subd. 2, "Righto of subjects 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 furnish certain private or confidential information. <br />You are notified that: <br />1. The information you fiimish wilt be used to determine your qualification for the permit or <br />lioansa 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 pemiit or license requires Council action to approve, some information <br />may baoome public. <br />5. You have certain righto 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 />Rrst fi Last <br />/i/1 <br />State zip Phone <br />updvttand my righto apfated above. <br />Signature <br />♦• • <br />/? <br />f • <br />r. <br />i ii "1C 4 <br />tiiiAdb