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f <br />CITY of ORONO <br />Peatommeaafa•Cry W1ea1.w,-. .."5023•M.nkip.1Omcs <br />a <br />• • • • On the North Sham of Lake Yinneto:-As. <br />DAT-I PRIVACY ADVISORY <br />In accordance with M.S. 15.1.65, "Rights of subjects of data", <br />we would like to inform you that your request for a 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 refvsal may require <br />that the City deny the permit or license. <br />1. The information may be shared with other 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 reqires council <br />action to approve, some informatior, may `,ecome public. <br />5. You have certian 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 />rat a ast <br />LC6/L <br />A res■ <br />Date of birth <br />key 63w <br />@ cc nne <br />f and •tend mJy rights as stated abov <br />gnOruro <br />-el}}Mt • AaUFFIRMATIONA nN.)-47)IHI • WWCWok" -e1}1 Xm <br />