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’ 1 <br />■ V <br />xaiiA. <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "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 chat: <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 the permit or license. <br />. The information may be shared with other local, state <br />or federal agencies to the extent necessary to process <br />t.he permit or license. <br />4. If your requesuid permit or license recires council <br />act'on to approve, some informacion may become public. <br />5. You have certian rights nder ^!.S. 15.165 tc review <br />private data on yourself. <br />6. Your full name, and date of : Lrth are required to process <br />thit. -application or permit. <br />First Middle Last <br />V V'O CSAV (tXJAO <br />Address <br />Date of birth (does not apply to building/general permits) <br />Phone <br />I understand ny rights as stated above. - <br />X ^ _-,r- <br />Signature