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DATA PlIVACY ADVISORY <br />In accordance with M.S. 15..165, "Rights of subjects of data", <br />we would like to inform yca 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 to 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 />*he Permit or license. <br />4. 'F your requested permit or license reqires council <br />action to approve, Some information may become public. <br />5. You have certian rights under N.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 application or permit. <br />/ n�� I 1,3,,I /lJ <br />rat Mic , e <br />Tess <br />Date of birth oes not apply to building/general permits) <br />LA"?l-����tl <br />Phone <br />I un"at d my rights as s ated above. <br />i� <br />gna ttire . <br />