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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 <br />to inform you that your request for a pe rmit or license from the City of Orono or any of its <br />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 <br />the permit or license requested. <br />2 . You may refuse to supply data , but refusal may require that the City deny <br />the permit or license. <br />3. The information may be shared with other local, state or federal agencies to <br />the extent necessary to process the permit or license . <br />4 . If your requested permit or license requires Council action to approve, some <br />information may become public. <br />5. You have certain rights under M .S . 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 Middle <br />Address <br />L_g,,[C.. ½f«(c- <br />City <br />I understand my rights as state~ve. <br />1) <br />Signature <br />8 <br />A'1) <br />State <br />Last <br />1lTf1JZ <br />Z ip <br />r r1-. '"ftff, a-Jrt. <br />Phone