Laserfiche WebLink
•1 <br />I * <br />' ,> <br />i^- <br />I <br />[. <br />I. <br />tL <br />ii <br />r <br />7 <br />»V‘ ^t *. • ^ <br />f <br />/ ''A « <br />; J ;•> • <br />‘ -1/ ' <br />% <br />« . :^‘ <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. IT-. 165, "Rights of subjects of data”, <br />we would like to inform you that your request for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform­ <br />ation . <br />You are notified that: <br />1.The information you furnish will be used to determine <br />your qualification for the permit or license requested <br />2.You may refuse to supply data, but refusal may require <br />that the City deny uhe permit or license. <br />3.The information may be shared with other local, state <br />or- federal agencies to the extent necessary to process <br />the permit or license. <br />4 .If your requested permit or license reqires council <br />action to approve, some information may become public. <br />5.You have certian rights under M.S. 15.165 to review <br />private data on yourself. <br />t.Your full name, and date of birth are required to process <br />this application or permit. <br />E P,u> irvi [) t t 'j M f-I;0/71 iTH <br />First Middle Last <br />5' <br />Address <br />.i *' IV )s-/ tS u J z 5" b' 3 5"6 <br />-/ / ' / /3-7 <br />Date of birth (does not apply to buildihg/general permits) <br />H I I - <br />Phone <br />erstand as stated above. <br />ignature • • <br />. - ....... -. * . .. <br />' » • . a.» • «•••«»« <br />*•.