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J <br />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 />First <br />Address <br />'DP-o~o <br />City <br />I <br />Signature <br />Packet Last Updated: January 2015 <br />~ l?.ANQ... <br />1 <br />1 S 4--\ \ LLi E"~ <br />Middle Last <br />55391 <br />Zip <br />Page 13 <br />4, 1 :;___ -~ l 9 -:)_4--l/ f <br />4J 37 46 <br />Phone <br />RECEIVED <br />MAY ? n 201 5 <br />CITY OF O~ONO