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* d <br />i % <br />- A <br />•1 ir! <br />^ 1 <br />tjT <br /><lJ <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights <br />data", we would like to inform you that your request for a <br />license from the City of Orono or any of its <br />you to furnish certain private or confidential information. <br />'t /'<,i -AvV <br />y iVf --rir^* <br />*!** ■>'• }'■ <br />. f •-ye <br />V V-. <br />& <br />'.S' <br />•You are notified that: <br />1, The information you furnish will be used to determine your <br />qualification for the permit or license requested. <br />2. You may refuse to supply data, but refusal may require that <br />the City deny the permit or license <br />3. The information may be shared with other H <br />federal agencies to the extent necessary to process the permit o <br />license. <br />4. If your requested permit or license acquires Council action <br />to approve, some information may become public. <br />5. YOU have certain tights under M.S. 13.04 to review private <br />data on yourself. <br />6. your full name is required to process this application or <br />permit. <br />JSS <br />Address <br />fi2o/s/r/SVf^C /W <br />City <br />((^/)) <br />Pnone <br />State ZTp <br />1 understand my rights as stated above. <br />Signature <br />■rM^lllHlli 'lifitiT alts -----