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1 <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", <br />we would like to inform you 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 />the permit or license. <br />4. If your requested permit or license reqires council <br />action to approve, some information may become public. <br />5. You have tertian 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 application or permit. <br />0 bc _i t1 2y J _-t f— <br />First Middle <br />G y 1 <br />Address <br />1— 0v <br />Date of birth —(does not apply to t. ling/general permits) <br />411- k 36 <br />Phone <br />1 understand my rights as stated <br />x <br />gnature <br />