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• • <br /> DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br /> warning", we would like to inform you that your request for a permit or license from the City of Orono or <br /> any of its departments may require 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 qualification for the permit or <br /> license requested. <br /> 2. You may refuse to supply data, but refusal nay require that the City deny the permit or <br /> license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information <br /> may become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04 (see following page) to <br /> review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> R CLOR P► ) eS t /, Lc <br /> First Middle Last <br /> cio p� U . da hicl 450v <br /> (5 0 o UUGw,,2a-I-u- NV OL / S('�-'4 e, 104 <br /> Address c <br /> WO-26 7,04-a— 117)Ni Cs 39 I qcg--41s-iq 0-7 <br /> City State Zip Phone <br /> I understand my rights a stated above. <br /> /17 <br /> Sigat?-°n I 1 4 6 v"t.-1‘ t- <br /> RECEIVED <br /> JUL 17 2013 <br /> CITY OF ff3,9Ngs <br /> Packet Last Updated: 03/29/13 # 36 <br /> Page 14 of 29 <br />