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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you <br />that your request for a permit or license from the City of Orono or any of its departments may <br />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 M.S . 13 .04 (see following page) to review private data on <br />yourself. <br />6 . Your full name is required to process this application or perm if- <br />8 'r v1 a. f o.))ucL <br />First -~ ~ ~(Jddl l~j 11 I Last I _) V\} /J Co-C tg _ f!L ~ . ,QI_ t '-ot,. <br />Address ' ' ~5 9 / 0 11-0 V'\.,-(> MN, <br />City State Zip Phone <br />Signature <br />#3293 <br />,;