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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'2ermit. <br />m~L-N,e,,~ ,~ <br />First ,-. ,~ M~le Last <br />-003~ Bei;l'.L VtAc-f: <br />Addres§...- <br />t:::-r~ N:A /)A,J <br />City "s{ate <br />5542-4 <br />Zip <br />@z) 9:M-D7o/.., <br />Phone <br />Signature