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AATA PRIVACY A0VI80RY <br />In accordance wtth Minnesota State Statute 13.04 Right$ of Subjects of Data. Subd. 2, "Tani ssen waming°, x® <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 fumish certain private or confidential information. <br />You are notified that: <br />f. The information you furnish will be used to determine your qualification 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 folloyAng page) to review <br />private data on yourself. <br />S_ Your full name Is required to process this application or permit <br />Ti 1m! � L Dftiwt- <br />First f Middle Last <br />V565 &Nsik 2d <br />Address <br />OQMr VJ 5535"� <br />city State 2im or,. <br />I understand my rights <br />�aass(�stated above, <br />Signature ' "' <br />RECEIVED <br />vaarerr:a,r Waor a 4aar 201a Pap 13 OCT 2015 <br />C" OF ORONO # 37 94 <br />