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-DATA-P-RtVAC'Y ADV!SORY <br />In accordanc~ with M.-S. 13:04, -Subd. 2, "Rights of"'Sttbfecls of ,data'', -we wowd ~ike t-0 mf.orm you that <br />your request for a permit or license from the City of Orono or any of its departments may require you to <br />Ttlmistl certam ,private-or confidential information. <br />You are notffied 1tlat: <br />· 1. The information you furnish will be US$d to determine your qualification for the permit or license <br />r~ed. <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 />lo -process -the -permit -or 1icense. <br />· 4. If your requested permit or license requires Council action to approve, sorne information may <br />oe'COTm:!-pubiic. <br />· 5. You have certain rights under M.S. 13.04 (see fol!owing page) to review private data on yourself. <br />c. -Yourtu1t mmre is required to process-this application or-pem,it. _ <br />TZ{~#,rµ.!1 v Y--iLJL~.) <br />FIR~,... ,----~ MIDDLE LAST ~Ji9 r/ ~ -c.....o tft::1::. . <br />CITY STATE. ZIP PHONE <br />/ <br />-14 ~ <br />,es 'O\ao !SOE! S9 OU I 'SiiW.tlU ".+U9WU '.J~: ·ns 3r