Laserfiche WebLink
40 <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 15.165, "Rights of subjects of data", <br />we would like to inform you that your request for a permit or <br />license from the City of Orono or any of its departments may <br />require you to furnish certain private or confidential inform- <br />ation. <br />You are notified that: <br />1. The information you furnish will be used to determine <br />your qualification for the permit or license requested. <br />2. You may refuse to supply data, but refusal may require <br />that the City deny the permit or license. <br />3. The infcimdtion may be shared with other local, state <br />or federal agencies to the extent necessary to process <br />the permit or license. <br />4. If your requested permit or license reaire� council <br />action to approve-, some information may become public. <br />5. You have certian rights under M.S. 15.165 to review <br />private data on yourself. <br />6. Your full name, and date of birth are required to process <br />this application or tcrmit. <br />FPr,hK kale <br />First I Middle Last <br />1�95' row h �• Se• <br />dyes -ram 5 3 9/ <br />Date of birth(does not apply to building/general permits) <br />�i lBr V 77S <br />Phone <br />I un rstand my rights as stated above. <br />X <br />Vigtu <br />