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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 i, permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are notified 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 nay be shared with otl,.er local, state <br />or federal agencies to the extent necessary to process <br />the permit or license. <br />4. if your requested permit or license regires council <br />action to approve, same 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 />Last <br />amiss -_ <br />to o'birth (dons not apply to tauildinq/general permits) <br />.1 <br />I understand my rights as stated above. <br />�( , _ 1 _1OE _. <br />�'i"gna ar a <br />