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DAT A 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 pe_rmit. <br />First Middle <br />7 ~o S'o. /J y1 OWN ~ <br />Address <br />lu ,-</ y "b4P9 <br />City <br />Signature <br />,. "\ --'•:_ . <br />r:-., ··:·j <br />.. ,.-...~:--_.r· <br />Last <br />AN' f"S-J<t1 <br />State Zip <br />• 'i.. ···-=• <br />'l S'l -l.t'J?-"7 J,5"' 7 <br />Phone <br />1 )