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CL <br />DATI, PRIVAC'i 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 derartments may <br />require you to furnish certain private or confidential inforin- <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 refuse to supply data, but refusal may require <br />that the City deny the permit or 'license. <br />3. The information may be shared with other local, state <br />or federal agencies to t e :ct necessary to process <br />the permit or license. <br />4. If your requested permit or license .egires council <br />action to approve, some information may become public. <br />5. You have certaan rights under M.S. 15.165 to review <br />private data on yourself. <br />6. Your full name, and date of birth are required to process <br />this application or permit. <br />First middle Lait <br />Address <br />UPS► MN • S3`3 i - - <br />1-7 'JL`f 19'1! <br />Date of Sirth(does not apply to 1)uilding/general permits) <br />3-oQ-3$ t 4 <br />Phone� <br />I understand rights as stated above. <br />x � r AA <br />