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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 furn i sh certain private or confidential information . <br />You are notified that: <br />1. The information you furnish will be used to determ ine your qualification for the permit or <br />license requested . <br />· 2 . You may refuse to supply data, but refusal may requ ire 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 />you rself. <br />6 . Your full name is required to process this application or permit. <br />~arr.i ~q_fh/~-evi 2/~0ttr1~ <br />First f.2 ~ ! Middle Last :6l-o rny,(r'~f w11 if <br />Addres~J ! vn, a fl 'l,4tts ~ m 1J <br />City State <br />I understand <br />Signature <br />r-ll.fi '-("' co <br />ff" /I II ,J w <br />153G 'i <br />Zip <br />f5J_ ,G/?f'-7fJO '( <br />Phone