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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 yo, that your request for a perr t or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or c:)afidential 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, bu= refusal may require <br />that the City ddny the permit or license. <br />3. The information may be shared with other local, state <br />or federal agencies to the ex,:ent necessary to process <br />the permit or license. <br />4. If your requested permit or license regires council <br />a-tion 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 date of birth are required to process <br />this applicu--ion or permit. <br />First Middle L,pst <br />Address <br />LA-) A X 7- ,,4 14-1 A) <br />Date o.f birth(does not apply to building/general permits) <br />Y 7y 9S7 8 <br />Phone <br />I unde�s and my right e. sted ve. <br />x <br />nature <br />