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f <br />r� <br />In acc::rdance wita M.S. 15.165, "Rights of subjezts of data", <br />we would like to inform you that your req.:est for a permit or <br />license from the CI of Orono or any of its departnents may <br />rr:u:_e you to furnish certain private or c::;nf:dential inform- <br />at_::r.. <br />You are notified that: <br />�. <br />The infor-nation you furnish wi''_ be _se,.= tc determine <br />your qual4f_1_2tion for the per-mit or :_z_::se req.;ested. <br />2. <br />You may re -'•.;se to su.p:y data, but refisal may <br />require <br />that the C.ty den! the or license. <br />3. <br />The infor:rat_on may be share! w_ _.. ct: e_ <br />or federal agencies tr tine extent ne,ressary to <br />p:cc�ss <br />t :e permit Cr :_tense. <br />-- .,^ur r__ _-_ -'= =e. _t cr 1_cense rec_res :.....nc4 <br />action to i_ C _n!z matior. ma. cecor;,a <br />publ_c. <br />5. <br />You have ce_.._an __, .ts under M.S. 15.165 to r-eview <br />private data on yourse=.`. <br />6. <br />Your fj.: name, and date of birth are required <br />to process <br />or rer-nit. <br />ata o l'Ces n 1. _1 t: ::U�_:-^.y^,'.j@ r1► ��^i�ts} <br />I understand ny ,hrs as <br />X <br />ianature <br />