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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 that <br />your request for a permit or license from the City of Orono or any of its departments may require you to <br />furnish certain private or confidential information. <br />You are notified that: <br />1. The information you furnish wili be used to determine your qualification for the permit or license <br />requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br />3. The information may be shared with other local, state or federal agencies to the extent necessary <br />to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information may <br />become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review private data on yourself. <br />6. Your full name is required to process this application or permit.LL.MIDDLE <br />LL.'.f ? <.* / (I ll 1 ► »/. <br />in <br />LAST <br />ADDRESS <br />i 'U-'. 1 y- •/ <br />/ <br />s A l 9 / <br />CITY STATE. ZIP PHONE <br />I understand my rights as stated above. <br />Signature <br />-14-