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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13 .04, Subd. 2, "Rights 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 for the permit or <br />license requested. <br />· 2. You may refuse to supply data, but refusal 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 to the extent <br />necessary to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information <br />may become public . <br />5. You have certain rights under M.S. 13 .04 (see following page) to review private data on <br />yourself. <br />6 . Your full name is required to process this application or permit. <br />First ,,--,,11 <br />/CfkS /J,,, <br />Address <br />Olt' -c?)A12 <br />City <br />Signature <br />above. <br />(__ <br />/44n <br />State <br />Last <br />'j <br />,, \ <br />' \ <br />fs L cf7?SoS3 <br />Phone <br />; ) <br />:r-. <br />J <br />'