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M. -q.V .< \ IITM •>. -V r,* * •» »s <br />DATA PRIVACY ADVISORY <br />yorto" fu?nish^ Vrivate°or confidential information. <br />[ <br />V - <br />.if . <br />You are notified that: <br />1. The information you furnish will be u*®-! t® aetermine 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 ' _VjS>it %lfederal agencies to the extent necessary to process the permit <br />license. <br />4. If your requested permit or license Council action <br />to approve, some information may become public. <br />5. You have certain rights 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 />First Middle Last <br />-^4-V 3^ sr\ f , • <br />Address w <br />] ^ A ■ 1 /Vfu. <br />City ^State zip <br />4/1^- S3S3 <br />Phone <br />I understand my rights as stated above.