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CITY of ORONO <br />PatDmm aw N•Crya l Bay. MinnmW'SJ29•Muniaiwl om,a <br />e <br />On the !North shore of Lake hliwnefoahe <br />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 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 •.) 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 federal agencies to the extent necessary to process <br />the permit or license. <br />6. I£ your requested permit or license reqires council <br />action to approve, some information may become public. <br />S. You have certiin rights under M.S. 15.165 to review <br />private data on yourself. <br />6. Your full name, and data of birth are required to process <br />this application or permit. <br />oF�e <br />I understand_ my rights as stated above. <br />x ..4� A,-���•C 0 <br />natura —� <br />aeaae•sa l0ls:r-a)})µ) • <br />aaaarte ADOWNISAIRW A felA-a)})ye • WRlrwwaaY_t)})Mf <br />