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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 fits <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 qualificatioj for <br />the permit or license requested. <br />2. You may refuse to supply data, but refusal may require that the City .eny <br />the permit or license. · <br />l <br />I <br />3. The information may be shared with other local, state or federal agenci~s to <br />4. <br />5. <br />6. <br />the extent necessary to process the permit or license. I <br />l <br />If your requested permit or license requires Council action to approve, s~me <br />information may become public. <br />l <br />You have certain rights under M.S. 13.04 (see following page) to retiew <br />private data on yourself. 1 <br />Y~ur full name is re9uired to process this application or permit. <br />'. I '· <br />First Middle Last <br />-; Ii 7 <br />~--t '.o > <br />Address <br />I underst9 n.d my rights as stated above. <br />u~t::711/· r1// ,./ <br />Sig ture <br />10