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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br />warning", we would like to infonn you that your request for a permit or license from the City of Orono or any <br />of its 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 the permit or <br />license requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or <br />license. <br />3. The information may be shared with other local, state or federal agencies to the extent <br />necessary to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information <br />may 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 />First <br />Address <br />City <br />I understand my rights as stated above. <br />W/ <br />Zip <br />Phone <br />r." U <br />Subdivision AppliCatfon — January 2077 Page 13 <br />3977 CITY OF ORONO <br />