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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you <br />that your request for a permit or license from the City of Orono or any of its departments may <br />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 qualification for the permit or <br />license requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or <br />license. <br />3. The information may be shared with other local , state or federal agencies to the extent <br />necessary to process the permit or license. <br />4 . If your requested permit or license requires Council action to approve, some information <br />may become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review private data on <br />yourself. <br />6. Your full name is required to process this application or permit. <br />-/iw.o-Hty Vi R,G,it. R.-\-e.vsoll'\ <br />First Middle Last I fo'+l S U"1ck Ave . <br />Add ~ess . <br />L-Gt Ke vi I le... , MN -(qs2..) aqe-s~'I- <br />City State Zip Phone <br />Signature <br />I understand my rights as stated above. <br />-I ..:..:....9 V. ?....-t-..........,,__ <br /># n 0 9 1 ~<? ' ' <br />~~ .d_::(.vt"' <br />r /) ..... ,.~ j ~~d t·-~· ,