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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 <br />you 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 <br />or 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 />,c~~ ·N\Uit)~ v~ <br />First Middle Last <br />Address <br />City <br />MJi <br />State <br />5.54.24 (uz) 811-070 <br />Zip Phan <br />I understand mj)JQQ)/\'eQ!l_ <br />,; <br />Signature