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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br />would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br />may 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 license <br />requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br />3. The information may be shared with other local, state or federal agencies to the extent necessary <br />to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information may <br />become public. <br />5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review <br />private data on yourself. <br />6. Your full name is required to process this application or permit. <br />5-t-~h"' )') RalJb~ <br />First Middle <br />Ji-too GoilJ f./Y f=h,-,< lcPaJ <br />Address <br />C>r C)I) {!) Ht0 <br />City State <br />I understand my rights as stated above. <br />Signature <br />Packet Last Updated: January 2015 <br />Bko-ti- <br />Last <br />~S--~q I <br />Zip <br />Page 13 <br />RECEIVED <br />JUL 2 2 2015 <br />CITY OF ORONO <br />qs z .... 2.,0.,. 2t5S-s- <br />Phone <br />#3773