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7 ff <br />(rr>.mrrJ J <br />y .*-1- ■ <br />V-x,^ <br />// <br />. * <br />! 1 /4^,: <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br />data"^ 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 requi <br />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 <br />qualification ^^r 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 local, state or <br />f;deLl agencies to the extent necessary to process the pern.it or <br />license. <br />4. If your requested permit or license inquires 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 />ll /-Lvrti iumi <br />LastFirst Middle ^ <br />I <br />V. <br />Address <br />-PI \jclt)l state Zip <br />Phone <br />I understand my rights as stated above. <br />\ f ly .'I <br />gnature