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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rig hts of subjects of data", we would like to inform you <br />that your request for a permit or license from the City of Orono or any of its departments may <br />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 f or the permit or <br />license requested. <br />2. You may refuse to supply data, but re fu sal may require that the City deny the permit or <br />license. <br />3. The information may be shared with other local, state or federal agencies t o the extent <br />necessary to process the permit or lieense. <br />4 . If your requested permit o(license req uires Council action to approve, s om e information <br />may become public. <br />5. You have certain rights under M.S. 13 .04 (see following page) to review p rivate data on <br />yourself. <br />6. Your full name is required to process this application or permit. <br />-=ros ep h t~ven e ✓ <br />A~r¥S <br />'8:-tl~ <br />City <br />I under~ss~ve <br />Signatu =7- <br />State Zip Phone