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CITY of ORONO <br />�t KESK���o e�tisn.,a�.s�aoeF <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.03. Subd. 2. "Rights of subjects of data", we would like to <br />inform you that your request for a permit or license from the City of Orono or any of its <br />departments may require you to furnish certain private or co:tfidential 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 />extent necessary to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some <br />information may become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />PLEASE PRLYr <br />/*011 /"'/ <br />First <br />- // iJ <br />Middle Last <br />7.:;y5- �r_� <br />t 4 <br />Address <br />Cita• <br />State Zlp Phone <br />I understand my rights as stated above. <br />TFI.FDnONE-477357 • FAx-VW10 <br />10 <br />