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ikylMUi Killi OF OMM ♦M2t4l4|ll THil F.NI/MI MSI <br />cmrof <MiONo <br />nSOMIqrNrtMV <br />OioM. MN 893M Cmttlqb m SS323 <br />DATA PMVACV APVMORY <br />IiiaccafdmcewiihM.S. 13.04,Sub4.2,*RifbiiorsttbjeGtsefd«ii*,wBwouldlilGBioiiiionayootety<ow <br />request for A permit or license ftom th* Chy of Orono or any of its deputnents m^y to fioniih <br />certain prWate or confidential infbrmation. <br />You are notified that: <br />1. The information you Aimish will be used to determine your qualificatioo for the permit or U ccdm <br />requested. <br />2. You mi^ refuse U) supply data, but refusal may require that the City deiqr the permit or li <br />3. Tbe Infbnnatkm may be shared widi other local, sute or federal agwocies to the extent neceasan^ to <br />process tbe permit or license. <br />4. If your requested permit or license requires Council action to approve, aotne ioformation may baeoma <br />public. <br />5. You have oenaio rights under M.S. 13.04 to review private data on <br />6. Your ftill name is required to process this application or permit. <br />NAMFi _____________sSrmt^___^ <br />first t <br />iRtfSSr <br />heesc number <br />i —Deis/,lb <br />'Jatreet <br />h O.jf Ofttf SMI <br />eky ’ <br />DATE OF BIRTH: <br />stale <br />/■I 1 H PHONE <br />moatik/ day / year <br />I understaiid my rights as stated abovA <br />= CiS3.- “iyi-sx^o <br />4lU QZ <br />date <br />Mephana (H2) 24MM • Dm <pa> MMili <br />I If -