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DA,rA 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 fr3m 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 feZeral agencies to the extent necessary to process <br />the permit or li,:ense. <br />If your requested permit or license regires council <br />acticn to approve, some information may become public. <br />S. You have certian 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 />First H dale Last <br />7 <br />Ad d r ss <br />Date o birth (aoesrnot apply to building{general permits) <br />y 7 2- G' <br />Phone <br />I understand my rights a5 �tated above. <br />X <br />Si(i i ature <br />