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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 <br />to inform you that your request for a permit or license from the City of Orono or any of its <br />departments may 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 <br />the permit or license requested. <br />2. You may refuse to supply data, but refusal may require that the City deny <br />the permit or license. <br />3. The information may be shared with other local, state or federal agencies to <br />the extent necessary to process the permit or license. · <br />4. If your requested permit or license requires Council action to approve, <br />some information may become public. <br />5. You have certain rights under M.S. 13.04 (see following page) to review <br />private data on yourself. <br />6. Your full name is required to process this application or permit. <br />First - <br />Address <br />fu I N N t;A:\t>\, '"~ <br />City <br />Middle Last <br />~~ <br />State <br />I understand my rights as stated above. <br />~~ :3-1S-0'1- <br />Signature <br />7 <br />~,'2.-~qq-9~9<-( <br />Phone