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1 <br />05>87/2ee3 14:09 6516985203 GRAY*STIMSO PAGE 03 <br />Iiar07>2001 I0:4lu FroKITY OF OWNO ♦HtMMIIS T*40l P.OH/OOi F-727 <br />GlTYor ORONO <br />OfBccs <br />umnutnm <br />Z7S0 MKy NrtMny <br />Omu, MN S53SS <br />amaguaia: <br />P.O. en 66 <br />Clistal 9v. MN SSt IV <br />PATAmRlVACYAPVlSORY <br />lateeordancewitbM^. 13.04, Subd. 2, 'Wglitsofsubjectscifdati”,wf would like to inform you ttiityour <br />request for a peimK or license from the City of Orono or any of its departmeno may require you to fumifo <br />certain private or confidentia] infomadon. <br />^^ia£n you furnish will be used to determine your qualificadoo for the permit or license <br />requested. <br />2. Youmqyrefosetosupp^data, but refosalnu^ requite that die City deny the permit or license.— <br />3. Tba information may be shared whh ocher local, state or federal ageoelea to die extent necessary to <br />process the permit or license. <br />4. If your requestad peimit or license requires Council acdon to ^lpIove, some informadoo may become <br />public. <br />i <br />$. You hAve cefttin righti imdtr MS. 13.04 to review privete data on yourself. ‘ <br />6. Your foil name is required to process this appUcarion or parmit <br />Kd-vW Gl ____NAMJC: <br />first middle <br />ADDRESS:eji^ <br />house number street <br />nau <br />DATE OF BIRTH: <br />L.10! hS-PHONE: <br />noath/ day f year <br />ted above. <br />/ 7 /os' <br />tare dam <br />UepbeoaCMDUMSOO • las <br />«nrmcLBtono.miuai <br />MMfU <br />L_mai.ei ■ —..................................—^