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I <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. vou may refuse to supply data, but refusal may require <br />nat the City deny the per -nit or license. <br />3. -he 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. :f your requested permit or license regires council <br />action to approve, some information may become public. <br />5. You have certiin rights under M.S. 15.165 to review <br />private data on yourself. <br />6. ':our full name, and date of birth are required to process <br />this application or permit. <br />First Mi a Last <br />Address <br />Date of birth ( oes not apply to building/general permits) <br />J <br />t, , �,,, , . ,1• <br />Phone _ LJ <br />I understand my'rights as stated above. <br />X r <br />i nature <br />