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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd . 2, "Rights of subjects of data", we would like to inform you <br />that your request for a permit or license from the City of Orono or any of its departments may <br />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 t o .... approve , some information <br />may become public . <br />5. You have certain rights under M .S . 13 .04 (see following page) to review private data on <br />yourself. <br />6. Your full name is required to process this application or permit. <br />First \ . r '\ bl ± Middle 12-cn \NI t-U'l U.f:S ::Tw) 1 Address <br />D roY\o <br />City <br />I understand my rights as stated above . <br />. Sig~ <br />Last <br />OroY10 , MA! <br />State Zip Phone