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DATA PRIVACY ADVISORY <br />In accordance with M S 13 04. Suba. 2. ’Rights of subjects of data”, we wo j d like to inform you that <br />your request for a pemnit or license from the City of Orcno or any of its depaments may require you to <br />furnish certain private or confidential information <br />You are nolifed that; <br />1. The information you furnish will 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 l.cense <br />3. The information may be shared with other local, state or federal agen&es 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 />becorre 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. <br />D C' ///?.• ' ♦- IV? M <br />FIRST <br />L L. .■ .• <br />MIDDLE <br />h 1 » ./. <br />LAST <br />ADDRESS <br />^ r,, 4 /JIK' <br />CITY 'STATE. ZIP PHONE <br />I understand my rights as stated above. <br />'> >----------- <br />Signature <br />14- <br />iite