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DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", <br />we would like to inform you that your request for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are notified that: <br />1. The information you furnish will be used to determine <br />your qualification for the permit or license requested. <br />2. You may refu•-e to supply data but refusal may require <br />that the City deny the permit it license. <br />3. The information may be shared with other local, state <br />or federal agencies to the extent necessary to process <br />the permit or license. <br />4. If your requested permit or license regires council <br />�tion to approve, some information nay become public. <br />5. Yc. have certiin rights under M.S. 15.165 to review <br />ptLvate data on yourself. <br />6. Your full name, and date of birth are required to process <br />this applic&tion or permit. <br />2" R-Ta,J . ., L rW u A r t c, , c •. L . <br />Firstmiddle, <br />ry 1�ae.S le'� �3p Last <br />1,40 <br />Addre s <br />©; - os-- $- <br />ate o rt(does not apply to building/general permits) <br />Al �/ - oobb <br />Phone <br />I a my.rig is stated a ve. <br />x <br />g r <br />