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0' <br /># <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 <br />license from the City of Orono cr any of its departments m?y <br />require you to furnish certain private or confidential inform-" <br />ation. <br />You are notified that: <br />1. <br />2. <br />The information you furnish will be used to detarnina* <br />your qualification for the permit or license recueste- <br />You may refuse to supply data, but refusal may requirt, <br />that the City deny the permit or license. <br />3.The information may be shared with otuer local, state <br />or federal agencies to the e.xtent necessary to process <br />the permit or license. <br />4 . <br />5. <br />6. <br />If vour requested permit or I’cense reqites council <br />action to approve, some information raay become public. <br />You have cartian rights under h.S. 15-165 to review <br />private data on yourself. <br />Your full name, and date of birth are requited to process <br />this application or permit. <br />•i <br />First;,, Midtn^ Q Last <br />Addressa/fl ^ rzv:rnh <br />Date of birth «loe~not apply to building/general permits) <br />47^ _ _ 1 <br />■ / <br />Pnone <br />.. ••. <br />. I undajifean^^y “® stated above. <br />T7^g nature I -i."- <br />..i- <br />■ <br />SSSS.-'.- . <br />•¥C.