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h, <br />CityofOrono <br />27S0 KeUey Parkway <br />P.O. Box 66 <br />CrysttI Bay. MN SS323 <br />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 your <br />request for a permit or license from the City of Orono or any of its departments may require you to furnish <br />certain private or confidential information. <br />You are notified 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 license. <br />3. The information may be shared with other local, state or federal agencies to the extent necessary to <br />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 to review private data on yourself. <br />6. Your full name is required to process this application or permit. <br />NAME:flrat middle last <br />ADDRESS:house number Street <br />DATE OF BIRTH: <br />city state <br />PHONE: <br />zip <br />month/ day / year <br />1 understand my rights as stated above. <br />•Igaature date <br />riOii