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P <br />H <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of suujects 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 cert:ian 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 />1"s la Vey �,a C1264-A p <br />Firse Middle Last <br />Address <br />E % Cam', n� Yt�l1 c c _ S -- - <br />Date of birth�cl oes not apply to building/general permits) <br />Phone <br />I understand my rights stated above. <br />X,,� �Iqnature <br />