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\/o o <br />'•a h ClTYoT ORONO <br />Miinidpai OfDcts <br />StmtMdrtn: <br />27SO Kdlcy Ptrintay <br />Orono, MN 55356 <br />MailiRilMratt: <br />P.O. Boi 66 <br />C>ystjl Bay, MN 55323-0066 <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2. "Rights of subjects of data", we woold like to <br />inform you that your request for a permit or license from the City of Orono or any of its <br />dv partments may require you to furnish 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 <br />permit or license requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the <br />permit or license. <br />3. The information may be shared with other local, state or federal agencies to the <br />e.xtent necessary to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some <br />information may tmome public. <br />5. You have certain rights under M S. 13.04 (sec following page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />First Middle Last <br />Qv^’^g\J€.io^tY\grt4 LLC ^*7^5" ?o\grr.S <br />Address <br />4-m <br />State <br />5'53ll mi. <br />Phone <br />I understand my rights as stated above. <br />/Signature <br />TeUphooe (612) 2494600