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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br />would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br />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 the permit or license <br />requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br />3. The information may be shared with other local, state or federal agencies to the extent necessary <br />to process the permit or license. <br />4 . If your requested permit or license requires Council action to approve, some information may <br />become public. <br />5. You have certain rights under Minnesota State Statute 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 />~~~ ~l~"''< 5-AN~ lt- <br />First Midde Last <br />2:2:2 .. tt tN N '=.-( ( l" ~V-H " <;o u'\1-\ <br />Address <br />Md'trJ l-A {o L.-,~ M,~ S'>" 'fu l l S I _3 u:S-S ~ l 0 <br />City State Zip Phone <br />7;:~~ <br />Signature ~ <br />Packet Last Updated: August 2015 <br />Page 13 <br /># 3814 <br />RECEIVED <br />FEB 1 7 7.018 <br />CITY OF ORONO