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.*r ;r <br />•# ^ <br />^ yrtm t* .>•ti i •• <br />■ y <br />DATA PRIVACY ADVISORY <br />you to furnish certain private or confidential information. <br />L„.. <br />-You are notified that: <br />1. The information y*^u furnish will be used to determine your <br />qualification for the permit or license requested, <br />2. You may refuse to supply data, but refusal may require that <br />the City deny the permit -'r license. <br />3. The information may be shared with other local, state or <br />federal agencies co the extent necessary to process the permit or <br />license. <br />4. If your requested permit or license requires Council action <br />to approve, some information may become public. <br />5. You have certain rights under M.S. 13.04 to review private <br />data on yourself. <br />6. Your full name is required to process this application or <br />permit. <br />First '^Middle <br />Ti^A rJig-f <br />Last <br />lO. PF^-£-^-) <br />Address <br />g-Q <br />City State Zip <br />^2334 <br />502Phone <br />i <br />. ■ , I~1B tfTi I ^ I ---------