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//O .. o <br />4"/ <br />•' ■■^ <br />r-‘ 1 <br />CITY of ORONO <br />PMOCIIc*B0Xi4 <br />Cr>^ MinnfiW 55323-0)66 <br />,r- <br />DATA PRI\ ACY ADM50RY <br />In accordance with M.S. 13.04, 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 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 />j. <br />4. <br />5. <br />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 />If vour requested permit or license requires Council action to approve, some <br />information may become public. <br />You have certain rights under M.S. 13.W (see following page) to review private <br />data on vourself <br />Y'our full name is required to process this application or permit. <br />First <br />I Vn. a7S <br />i\Iiddle Last <br />Address ' 0 <br />Cir\‘ <br />KViM SSSBG <br />State Zip Phone <br />I understand mv riahts as stated above <br />Sisnature <br />TELEPHONE -*^7357 • E\X-473-0510