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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, 'Tennessen waming", 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 confrdential information. <br /> You are notifled that: <br /> 1. The inforrnation you furnish will be used to determine your qualification for the permit or license <br /> req uested. <br /> 2_ You may refuse to suppty data, but refusaf may require that the City deny tt�e pe�rnit 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 Coundl action to approve, some information may <br /> �ieoome pub(ic. <br /> 5. You have oertain rights under Minnesota State Statute 13,04 {see following page) to review <br /> private data on yaurseif. <br /> 6. Your fuil name is required to process this application or permit. <br /> � <br /> First Middle Last <br /> l � r (,e� � <br /> Address <br /> �D U�- SS -� - �Z� <br /> C�Y State Zip Phone <br /> I tand my rights as stated above. <br /> �� <br /> Signature <br /> ��C���IED <br /> Padcet Lest Llpdatad: January 2015 p�13 M�R 10 2015 <br /> � � 7 �� ���1C �F +�RONO <br />