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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data , Subd. 2, "Tennessen warning", we <br />would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br />may 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 qualific ation for the permit or license <br />requested . <br />2 . You may refuse to supply data, but refusal may require that the City deny the permit or license. <br />3 . The information may be shared with other local, state or federal agencies to the extent necessary <br />to process the permit or license . <br />4 . If your requested permit or license requires Council action to approve, some information may <br />become public. <br />5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review <br />private data on yourself. <br />6. Your full name is required to process this application or permit. <br />JottN <br />First <br />Address <br />City <br />P acket Last Up da ted: January 2015 <br />Middle Last <br />State Zip <br />Page 13 <br />( (.Qt'2) {p-=fo -I g:g:3- <br />Phone <br />4t 37 48 <br />RECEIVED <br />MAY 2 0 2015 <br />CITY OF ORONO