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• 0 <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 may 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 /> GOCLO.e,NeAr Prore)(4-)eS , L, <br /> First Middle Last <br /> qo p'ci1 Cam W . d o k!'t b OYl <br /> (56 o o Wow,mhu N vol . r S - 164 <br /> Address <br /> WI u4a, 1 )NJ 5531I qc L-41 c -/°o7 <br /> City State Zip Phone <br /> I understand my rights a stated above. <br /> c— ;hz,L)i ---.-- I Al", ?s, LJ tk el cAA-_-. A-Ort^-11-1A,,L <br /> Signat re <br /> RECEIVED <br /> JUL 17 2013 <br /> CITY OF OfROAlgs <br /> Packet Last Updated: 03/29/13 <br /> Page 14 of 29 # 3 6 2 it <br /> 1 <br />