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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 />Rz SN <br />First liddle Last <br />Address - <br />M t li rj f'sq (o L t % <br />city <br />I understand my <br />Signature <br />state <br />as stated above. <br />Zip <br />SS <br />Packet Last Updated. August 2015 <br />Pays 13 # 3814 <br />—3 65-5 s 10 <br />Phone <br />RECEIVED <br />FEB 17 2016 <br />