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.J . <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", <br />we would like to inform yo) that your request for a permit or <br />license from the City of Orono or any of its departments --4f <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are nctified that: <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 />3. The information may be shared with other local, state <br />or fedeLal agencies to the extent necessary to process <br />the permit or license. <br />4. If your requested permit or license :egires council <br />action to approve, some information may become public. <br />5. You have tertian rights under M.S. 15.165 to review <br />private data on yourself. <br />6. Your full. name, and date of birth are required to process <br />this application or permit. <br />First, Middle Last <br />4d i ': tr -- <br />Address <br />I <br />l <br />Date of it does not apply to building/general permits) <br />PIZ"— <br />I understand my rights as stated above. <br />J <br />X1 <br />�) sgtkaLkire <br />